Bloating and gas are two very common symptoms of small intestinal issues. Your small intestine begins with the Pyloric Sphincter (the doorway between the stomach and the small intestine) and ends with the Ileocecal Valve (the doorway to the large intestine) and in-between is about 15-20 meters of tubing lined with tiny fingerlike projections called villi. These villi are epithelial tissue and are covered completely by thousands upon thousands of microvilli. They are accountable to the body to manufacture digestive enzymes (that will complete the digestive process of food), absorb nutrients and prevent the uptake of unwanted substances that will have no use in the body – they are efficient that way.
Sometimes there is a strain on the guts efficiency which can lead to some very severe problems. We are going to take a look at three such issues that can come from an off-balance of the small intestine (bloating arises in all these issues). Read with care, be skeptical, many of the symptoms that may be present for a specific issue arises for another. Take a deep breath and let’s dive in!
Loss of Migratory Motor Complex
Migratory Motor Complex (MMC), as Giulia Enders puts it in GUT The Inside Story of Our Body’s Most Underrated Organ, is the housekeeper of the small intestine. After you have eaten and all your food has left the small intestine by the Ileocecal Valve and entered the large intestine, the small intestine housekeeper comes into action and pushes all the leftover derby and bacteria right out of the small intestine. MMC happens about every 90 minutes during fasting. If you happen to eat every two hours or so, this process is either cut short or simply does not take place till you go to bed.
Now, this does not mean that you can’t snack, just make sure you listen to your body with care. When it tells you to eat, go and eat something. Yes, this can be harder than what you’ve just read. The first three months after I realized I needed healing from my eating disorder I had a hard time wrapping my head around what my body was telling me…. perhaps I had trouble listening, but my body also had trouble telling me. After ten years of having my eating disorder decide when I should eat or not eat or binge eat, it was hard to listen to what my body actually needed. It’s not a 100% all the time, I have funky days, but my body and I are finally on the same wavelength and I am finding it easier to listen to it with each new day!!!
Please note, if you are hypoglycemic, listening to your body is tricky. I won’t get into this now, but please stay tuned for a blog post specifically dedicated to this that will come in the near future!!
How do we end up losing our Migratory Motor Complex?
You go on a trip to some exotic place…or to the United States, or to a restaurant down the street. Truly you can get pathogenic bacteria (E.coli, Salmonella, Campylobacter jejuni, Shigella etc.) anywhere. Your stomach acid is responsible for breaking down food. It is also there to vanquish any bad bacteria that we may ingest with our food.
However, perhaps you are low in stomach acid or that delicious morsel you just ingested is topped with a whole bunch of something you don’t want. On top of that, your stomach decided to not send it back up the way it came in (vomiting). Now, this pathogenic bacteria is in your stomach and shortly will make its way into your gut. It begins to release cytolethal distending toxin (CDT), which puts our immune system on high alert as it will need to defend the body in combat against these bad guys.
As the pathogenic bacteria move into the small intestine and the immune system is firing missiles left, right and centre to eliminate as many of these troublemakers as they can, they accidentally partake in some friendly fire. There is a cell that makes up the lining of the gut named Interstitial cell of Cajal (ICC), whose job is Migratory Motor Complex. It is also this cells misfortune to look ever so similar to pathogenic bacteria.
So as the immune system is defending the body it also, by accident, brings great damage to the ICC of the small intestine. By damaging them MMC is also damaged and there is no longer a housekeeper present to sweep up the waste and bacteria that remain in the small intestine. Peristalsis may get rid of the rest later on, but not everything. This means a buildup of undigested food that will ferment and release gas in the small intestine (resulting in bloating), furthermore it will lead to an eventual overgrowth of small intestinal bacteria…..this leads us to the second stop on our journey.
Small Intestinal Bacterial Overgrowth (SIBO)
The small intestine will naturally have some bacteria in it (the good and the bad, approximately < 100 thousand and this bacteria mainly reside in the last portion of the small intestine called the ileum), however, it may come to happen, for instance if the MMC in the gut no longer works, that bacteria will build-up. Now, this is not necessarily the build-up of bad bacteria, it’s primarily the build-up of normal commensal bacteria (aka indigenous bacteria).
Another way we can get a build up of this indigenous bacteria is if the Ileocecal Valve is not closing properly. The small intestine will always (unless we vomit) move chyme forward. The large intestine will go to and through, up and down, for as long as it sees fit. This isn’t so much a problem if the Ileocecal Valve is closed, but if it has trouble staying closed bacteria has the potential to move on up into the small intestine. Now, let’s say that bacteria gets up into the small intestine from the large intestine, if MMC is working, eventually the bacteria will be pushed out and we don’t really have a problem (if it isn’t then we have an issue). However, if it is working bacteria still have a potential to multiply and reek havoc. How? The small and large intestine can get bowel pockets. These small crevasses will collect decomposing food and bacteria. This is the perfect little home for bacteria as it has food to munch on and it’s protected from the motion and commotion that is happening in the gut and here they will multiply. Bacteria have made their way into the small intestine … why the red flag?
Other reasons SIBO can develop
- Gastrointestinal (GI) infection – Crohn’s disease, ulcerative colitis
- GI Surgery – gastric bypass, blind loops, removal of Ileocecal valve
- Chronic Stress – digestion shuts off as we are often in a constant state of fight or flight.
- Age – with age the acidity of the stomach decreases = food not being properly digested thus leading to a possibility of bacterial overgrowth either through fermentation in the gut (food not being able to be absorbed by the body is left to feed them especially carbohydrates) or through the loss of MMC.
- Antibiotics – potential to change the microbial landscape in the Gut.
Symptoms of SIBO
- abdominal bloating/distension
- constipation or diarrhea or a mixture of both
- abdominal pain
- acid reflux/heartburn
- an exorbitant amount of farting and burping
- brain fog – trouble concentrating or remembering things
- tired or weak
- underweight or struggling to gain weight (does not manifest like this for all people with SIBO)
- many nutrient deficiencies
Why is SIBO an issue?
As was said above, the small intestine will have very few bacteria present (<100 thousand), it only becomes an issue when the indigenous bacteria grow out of control and begin to wreak havoc on the small intestine and subsequently the body as a whole. The damage they bring about includes the following.
Mucosal damage brings about inflammation to the epithelial lining of the small intestine (aka it dulls down the villi making them less efficient at the work they need to conduct).
Increased permeability of the digestive tract which can lead to the development of IBS (Irritable Bowel Syndrome) along with other digestive issues.
Deconjugation of Bile
When bile is released from the gallbladder it is conjugated (meaning there is a double bond), it needs to be in this form to break down fats in the small intestine. Bacteria will attempt to break these bonds apart – deconjugating the bile – if there is too much bacteria present this becomes a serious issue. a) we cannot absorb fat (or in the least a very small amount which by far will not be enough) – this will result in fat globules coming out of your stool (take a look at your poo…it will tell you a lot). b) deconjugated bile harms the cells of the small intestinal lining – primarily brush border enzymes. c) transporters on the small intestinal lining that bring nutrients into the body get damaged.
Bacterial Consumption of Nutrients
Bad bacteria and other opportunistic organisms in the gut will begin to compete and consume nutrients and in turn lead to the production of hydrogen, hydrogen sulphide and methane – hydrogen is linked to diarrhea and methane is linked to constipation (methane released by bacteria slows down transit time by 70% -that’s crazy I know!). Both will irritate the gut and bring about bloating.
Bacteria Secrete Their own Enzymes
These enzymes aid the bacteria in breaking down and digesting the food that they find in the small intestine, however, they are so potent that they can also begin to eat away at the lining of the small intestine. Furthermore, the enzymes that the bacteria produce also eat away at our carbohydrate and sugar-digesting enzymes (saccharide- digesting enzymes) making it difficult to absorb carbohydrates.
What nutrients does SIBO fight over?
The body is able to absorb dietary B12 only if it is attached to intrinsic factor (which is produced by the stomach lining -along with HCL and pepsin). The pair makes their way to the small intestine where they have hopes of being taken up and used by the body. Unfortunately, with SIBO this becomes an issue, as the bacteria love to gobble up B12. They strip it away from intrinsic factor and without that B12 cannot be absorbed. Over time this can lead to B12-deficiency anemia.
Vitamin A, vitamin D, vitamin E, vitamin F and vitamin K are essential fat-soluble vitamins and as bad bacteria like to deconjugate bile, they make it incredibly hard for us to digest fat. The assimilation of these nutrients into the body is assisted in the presence of bile salts and fatty acids in the intestine, however, if the bile is deconjugated and fat cannot be broken down this ‘aid’ cannot be given and many of these nutrients are not assimilated into the body. If it were to happen only a few times there would be no issue, but rarely (unless diagnosed) would someone be aware that there is an issue, and so over time malabsorption of nutrients leads to malnutrition.
Best way to test for SIBO
A methane and hydrogen breath test is the best way to test for SIBO. A stool sample test will not work as it will only be a reflection of the environment in the large intestine. The Hydrogen Breath test can be done at home, with a natural practitioner or at a hospital. There are two sugar solutions that are used, both cannot be digested by the human body, however, they are gobbled up by bacteria. After one consumes the sugar solution and the bacteria eat it they will release gas. The gas crosses the intestinal lining, moves to the lungs and we breathe it out (the gases that we breath out are measured).
The test takes approximately 2-3 hours, and one’s breath is tested every 20 minutes during this duration. The test is rated as such…
Hydrogen – 20 parts per million = positive
Methane – 3 parts per million = positive
Combined score of 15 = positive
- One of the two sugar solutions, ‘lactulose’ needs to be prescribed by a doctor.
- The test may make symptoms worse.
What can one do?
If you are feeling overwhelmed it is good to seek some advice and guidance, it’s hard to figure out where to start when you can’t really see your insides or pinpoint where the problem exactly resides.
However, here are a few little changes that you can make.
- Positive vibes – love yourself. This really can’t be stressed enough. It may not happen overnight, but making sure you put out a positive outlook on all aspects of your life will really make a difference in how you feel and how your body reacts to you.
- Them Carbohydrates – now we are not cutting out everything and living on protein and veggies alone if you happen to be at a birthday and you truly feel like having that piece of cake or pie, have it. Eat it, enjoy it, don’t gobble it up because you want it to be gone… if you want to eat it enjoy every bite!!
Now for those carbohydrates. We want to bring down their consumption because bacteria love to gobble them up. Fruits, vegetables and honey have simple sugars in them that don’t require a great deal of breaking down – making them quite easy to absorb. Grains are a little trickier. So are processed sugars. This goes for dairy products as well, not even the delicious fermented dairy, everything is out for the time being.
I’ve decided to leave the rest for Part Three as there was so much to get across (I will go into the third issue – IBS – and after that, we will look into the large intestine). I hope you found this an informative read. If you have any questions or if you’d like to read up some more on these issues you can check out my references below. Have yourself a beautiful day and until next time!!!
If you are interested in learning more about SIBO here is a great website to check out!!
Cutler, E. W., & Kaslow, J. E. (2005). Micromiracles: Discover the healing power of enzymes. United States: St. Martin’s Press.
DiBaise, J. K. (2008). Nutritional Consequences of small intestinal bacterial overgrowth.PRACTICAL GASTROENTEROLOGY, 69, 15–28.
Enders, G. (2015). Gut: The inside story of our body’s most under-rated organ. Australia: Scribe Publications.
Erdogan, A., Lee, Y. Y., Badger, C., Hall, P., O’Banion, M. E., & Rao, S. S. (2014). What is the optimal threshold for an increase in hydrogen and methane levels with glucose breath test (GBT) for detection of small intestinal bacterial overgrowth (SIBO)? Gastroenterology, 146(5), S–532. doi:10.1016/s0016-5085(14)61927-2
Ghoshal, U., Shukla, R., Agarwal, V., & Dhole, T. N. (2014). Fecal Microbiota in patients with irritable bowel syndrome compared to healthy controls by real-time PCR: An evidence of Dysbiosis. Gastroenterology, 146(5), S–532. doi:10.1016/s0016-5085(14)61926-0. Online Available at PubMed.
Gottfried, S., & Northrup, C. (2013). The hormone cure: Reclaim balance, sleep, sex drive, and vitality naturally with the Gottfried protocol. Philadelphia, PA, United States: Scribner.
Gottschall, E. G. (1994). Breaking the vicious cycle: Intestinal health through diet. Baltimore, Ontario: The Kirkton Press.
Hod, K., Ringel-Kulka, T., Van Tilburg, M. A., & Ringel, Y. (2014). Abdominal bloating in patients with irritable bowel syndrome: Characterization of clinical symptoms, psychological factors and associated Comorbidities. Gastroenterology, 146(5), S–532. doi:10.1016/s0016-5085(14)61925-9
Lipski, E. (2011). Digestive wellness: Strengthen the immune system and prevent disease through healthy digestion, fourth edition (4th ed.). New York, NY: McGraw-Hill Professional Publishing.
Siebecker, D. A., & Croxton, S. (2015). How to Beat the Bloat: Small Intestine Bacterial Overgrowth Retrieved from SeanCroxton.com
Siebecker, D. A., & Sandberg-Lewis, D. S. (2013, January 9). Small intestine bacterial Overgrowth: Common but overlooked cause of IBS. Retrieved August 19, 2016, from Naturopathic Doctor News and Reviews, http://ndnr.com/gastrointestinal/small-intestine-bacterial-overgrowth-2/
Siebecker, D. A., & Sandberg-Lewis, D. S. (2011, March 1). Small intestine bacterial Overgrowth: The case of the perpetual patient. Retrieved August 24, 2016, from Naturopathic Doctor News and Review, http://ndnr.com/pain-medicine/small-intestine-bacterial-overgrowth/