Yale doctors demystify common gut problems

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If the thought of talking to your doctor—or anyone—about constipation, diarrhea, bloating, hemorrhoids, and other similar issues gives you stomach cramps, you aren’t alone.

But if that discomfort about discussing your discomfort means you aren’t seeking care, Yale Medicine gastrointestinal (GI) specialists have a message for you:

They’ve heard it all before, and there’s nothing to be ashamed of when it comes to bodily functions.

“An overwhelming number of people who come into my office to talk about a GI problem say, “Oh my God, I am so embarrassed. This is so disgusting,'” says Jill Deutsch, MD, a Yale Medicine specialist in functional GI disorders.

“I frequently tell people that I play around in poop all day. I wear a poop emoji on my jacket. I feel cool and comfortable talking about it, and they shouldn’t worry.

I am a poop doctor. It allows them to take a breath and say, “OK, this is what is going on.” They open up and ask me questions.”

Another point Dr. Deutsch quickly makes is how common these issues are.

“People often feel like they are the only person with this problem, and that is never true,” she says. “Their problem is a lot more common than they think it is, and we try to normalize things.”

Below, Dr. Deutsch and her colleagues share some of the GI issues they frequently treat and suggest steps you can take at home—and explain when you should seek advice from a physician.

Constipation—defining ‘normal’ is not so easy

When it comes to treating patients with constipation (infrequent bowel movements or dry, hard stools), Dr. Deutsch first asks a lot of questions.

“I tell people that their normal may not be my normal or the next person’s normal. We are all very different when it comes to bowel habits,” she says.

“I need to know what the stool looks like, from the color to the length, and how long it takes you to go. If someone is only going once or twice a week and the stools are looking like little rabbit pellets, I need to tease that out.”

To help explain, Dr. Deutsch often shows patients a bell-shaped curve from a study published in Gastroenterology. “On the national average, people poop anywhere from three times a week to three times a day,” she says.

“That is a huge range. I stress that if you don’t feel good, we need to make you feel good.

If you are worried that you are sitting on the toilet for an hour and passing small, hard pellets, we should see if you are getting enough fiber or physical movement every day. Or maybe we need an over-the-counter or even prescription-strength laxative.”

Dr. Deutsch also doesn’t shy away from sharing her own experiences. “It can be TMI, but I let people know that we all deal with these problems once in a while,” she says.

“If I don’t go to the gym and I don’t eat any fruits and vegetables for a week, my poop looks like something my cat would produce.”

For treatment, many over-the-counter medications help in different ways. Colace, for example, is a stool softener that draws water into the stool to make it easier to push out.

Because it is not a laxative, it may take a few days for it to work. Senokot is a laxative stimulant that propels stool forward. Meanwhile, Dulcolax and Miralax are osmototic laxatives that draw water into the colon to make it easier to push stool out.

“People should definitely talk to their doctor about what to use. I always recommend starting with Miralax if you want to try something over the counter. It’s very gentle and easy and works after a few days of taking it,” Dr. Deutsch says.

There are three “flavors” of constipation, she adds. Chronic idiopathic constipation is “your run-of-the-mill constipation from not eating enough fiber, drinking enough water, or moving around enough,” she says.

“We can overcome this simply by adding more fiber into your diet and maybe using Miralax.”

Slow transit constipation is when pelvic floor muscles “become a little lazy,” Dr. Deutsch explains.

“If you are pushing and straining and doing acrobatics on the toilet, like rocking back and forth or twisting side to side, then the muscles forget how to work well together,” she says.

“We may need to do a rectal exam to figure out what is going on and refer you to physical therapy for help.”

The third type of constipation, colonic inertia, is rare, Dr. Deutsch says. “This is when the electrical impulses in the colon are weakened and the motion to move stool forward is not as strong as it should be,” she says.

“We don’t know what causes this, but there is an oral medication that helps.”

Bloating—there’s help

Bloating, which is when the GI tract is filled with gas or air and leads to a feeling of fullness or actual distension of the belly, is a common complaint from patients, Dr. Deutsch says.

“It can be hard to deal with, as it makes people feel like they are not physically desirable, and it can take an emotional toll on someone’s quality of life,” she says.

“And there are so many reasons why people get bloated. For instance, if a patient tells me they are constipated, that is our objective evidence; we can blame it on that and try to get their bowels moving more regularly.”

One tactic is to up your fiber intake. “Look for soluble fiber in your foods to get your bowels moving,” she says. Ideas include oats, apples, peas, and lentils.

If you can’t get enough soluble fiber in your diet, try Metamucil as a supplement, Dr. Deutsch suggests. And if none of these steps offers relief, Dr. Deutsch may consider if there are imbalances in a patient’s microbiome.

“If healthy bacteria are too abundant, for example, that can lead to the bloating,” she says.

A breath test can make the diagnosis of bacterial overgrowth, and then dietary changes and medications may help, she says.

Bacteria in the colon are meant to digest food and create stool, but if the stool sits there for a long time and the bacteria continues to work and digest, the bacteria creates gas, Dr. Deutsch explains.

“The gas can then fill you up like a balloon. And you can get these sharp and uncomfortable gas pains,” she says. “There are tons of ways we can target the gas and the bloating, but it is very individualized.

It might be Miralax for one person, a suppository or an enema for another. We have to see what someone is comfortable doing in order to feel better.”

Diarrhea—there may be many causes

In the GI world, there is a stricter definition of diarrhea than one might think.

“It’s not just watery stool or stool with no consistency, but also increased volume. People often come to me and say they are having diarrhea, but when you get into the fine details and find out they are pooping once or twice a day, that’s not it really,” Dr. Deutsch says.

“Still, it’s maybe not your normal. And I need to know if it holds shape or if it’s just literally water coming out.”

Dr. Deutsch says it is important to find out if there is any blood, which could be an indication of an inflammatory bowel disease (IBD) such as Crohn’s or ulcerative colitis, both of which involve chronic inflammation in the digestive tract and cause persistent diarrhea, abdominal pain, bloody stool, weight loss, and fatigue.

She says she also wants to know if someone is having accidents. “If it’s just a sensation that you can’t get to the bathroom in time, but you do get there, that is easy to fix,” she says.

“Common factors may be lactose intolerance or things like bacteria that exist in your gut. They do many jobs, but they can also draw too much water into your stool and give you diarrhea.”

If diarrhea is chronic and there are accidents, Dr. Deutsch may refer you to an IBD specialist.

“With ulcerative colitis, patients may have accidents when they can’t get to the bathroom in time because the rectum is so inflamed it can’t hold in the stool,” says Jill Gaidos, MD, a Yale Medicine physician who specializes in IBD. (See more on IBD below.)

When diarrhea is caused by a GI infection, however, it usually lasts a week or two at most, Dr. Deutsch says.

“We don’t see a lot of patients with infections because they usually start to feel better on their own before they come in. The body does a great job of taking care of most infections and very few require antibiotic treatment,” Dr. Deutsch says.

If you are a woman of reproductive age, there’s another potential cause too, says Dr. Deutsch:

“For women, diarrhea may be related to their menstrual cycle, which can lead to having softer, more frequent stools.

This is because of the hormone flux that occurs around the time of your cycle. Many women tell me they rely on their period to get them regular again.”

Stress can also cause diarrhea and constipation, Dr. Deutsch notes, speaking from experience. “When I take tests, I am in the bathroom 10 times that morning. The gut reacts very strongly to emotional and traumatic triggers,” she says.

“I wish we could better define these connections, like, hypothetically, if you are anxious, you’ll get constipated or if you’re depressed, you’ll get diarrhea. Traumatic mental health events can manifest as abdominal pain, bloating, and all sorts of things.”

What helps with diarrhea

Over-the-counter medications such as Pepto-Bismol and Imodium are generally safe for treating diarrhea, Dr. Deutsch says. “The only time you don’t want to take them is if you have a GI infection,” she adds.

“And people should also know that Pepto-Bismol can make your stool turn black, which makes some worry that they are bleeding. But this is normal. What’s concerning is blood.”

If you can, consider riding out the diarrhea before using an over-the-counter medication, as too much medication can then lead to constipation, Dr. Deutsch points out.

“Or if you do take a medication, you may just want to take one pill or one dose first, and give it a little time to work,” she says.

Diet is also key when dealing with diarrhea. “If it’s a vicious stomach bug, we recommend the “BRAT’ diet of bananas, rice, apple sauce, and toast. You want bland things that will help firm up the stool,” Dr. Deutsch says.

To avoid diarrhea in general, Dr. Deutsch recommends foods with insoluble fiber, which acts like a sponge and draws water out of your stool. Look for foods with whole wheat flour, wheat bran, and things like beans, nuts, cauliflower, and potatoes.

If you need a supplement, Benefiber works well because it absorbs water from the intestines to form softer, bulkier stool, Dr. Deutsch says.

Inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS)—when to seek help

Chronic digestive disorders like IBD and irritable bowel syndrome (IBS) make life complicated. Though they sound somewhat similar and both involve bowel problems, the more serious condition is IBD, whereas IBS is more of a catch-all category.

Some studies have shown that it can take four to five years to diagnose patients with IBD conditions like ulcerative colitis and Crohn’s disease, says Dr. Gaidos.

“Typically, bloody bowel movements will trigger medical care, and it might be Crohn’s, but not every Crohn’s patient has bleeding,” she says.

“IBD may cause intermittent abdominal pain and if it’s nothing specific, women, in particular, may be diagnosed instead with irritable bowel syndrome and a full evaluation is overlooked.”

IBS affects twice as many women as men and is a syndrome that can cause abdominal cramping, bloating, and a change in bowel habits. Its cause is unknown and there is no specific test to diagnose it, though a colonoscopy can rule out IBD.

Dr. Gaidos says she always reminds patients that bleeding is never normal. “If you pass a hard stool and there is a tiny bit of blood on the toilet paper, that may be OK, but if there is blood mixed in with your stool, that needs to be evaluated,” she says.

Not every patient needs to have a colonoscopy to diagnose IBS and rule out IBD, Dr. Gaidos says. “We also have stool testing that can check for markers of inflammation,” she says.

Most importantly, Dr. Gaidos wants patients to know they should never suffer in silence. “You don’t have to tolerate your symptoms,” she says.

“If your disease is impacting your quality of life, then talk to your doctor about ways to make improvements. If you have IBD and you used to go to the bathroom 20 times a day and now it’s 15, don’t settle for that.”

There is no cure for IBD but there are various medications that can relieve symptoms and sometimes create a period of remission in which the disease is not active.

Hemorrhoids—simple solutions can offer relief

When it comes to GI problems, hemorrhoids—swollen blood vessels in the lower wall of the rectum and anus—can be uncomfortable, causing itching, rectal bleeding, and pain.

But hemorrhoids, in and of themselves, are actually a part of everyone’s normal anatomy and at baseline we don’t even know they are there, says Anne Mongiu, MD, Ph.D., a Yale Medicine colorectal surgeon.

However, pressure on the pelvis from heavy lifting, long periods spent sitting on the toilet, difficult-to-pass bowel movements, excessive straining during childbirth, or just from being pregnant can cause them to enlarge dramatically and cause symptoms.

“External hemorrhoids often feel like large balls or grapes outside of the anus. They usually don’t bleed, but are very tender and can make sitting very difficult,” says Dr. Mongiu.

“Internal hemorrhoids usually cause painless bleeding, and can sometimes be felt as soft tissue that may stick out from the anus after a bowel movement. But they most often return to the rectum on their own or with a small push.”

To diagnose hemorrhoids, a doctor will do a physical exam to check for swollen tissues in the anus and likely perform a digital rectal exam (inserting a gloved finger into your rectum) to feel for internal hemorrhoids.

“Sometimes we may even use a very small or short scope [anoscope] that lets us look inside the anal canal to evaluate the hemorrhoid,” says Dr. Mongiu.

If hemorrhoids are mild and caused by constipation, increasing water intake to eight glasses per day along with increasing dietary fiber and/or adding a stool softener such as Miralax can dramatically reduce symptoms in just a couple of weeks.

Over-the-counter creams and prescription medications may also offer relief. If there is rectal bleeding, though, you should see your doctor to have a colonoscopy to rule out other conditions including colon cancer.

“If the colonoscopy doesn’t show any other causes of bleeding, we can work on treating the hemorrhoids in a step-up fashion,” says Dr. Mongiu.

Diet and lifestyle modifications, along with some prescription-strength hydrocortisone cream are usually the first line of treatment. If this is not effective, there are in-office treatments available.

“We have a banding suction device, which we put around the hemorrhoid to shrink the exposed portion in stages,” explains Dr. Mongiu.

“This takes a couple of minutes in the office, and most people only feel some mild rectal pressure after the banding; they can usually go back to work the same day.

Surgery is a last line of treatment—it is very effective, but also causes the most discomfort.” And recovery usually requires that you take a week or two off of work, she adds.

“In the end, the best treatment typically for hemorrhoids is diet and lifestyle, such as exercising, drinking water, eating well, and not straining on the toilet,” she says.

“You shouldn’t be sitting there reading text messages because it takes so long. If you have to throw some Miralax in your coffee, then do that, too.”

Burping and flatulence—good for you or just rude?

Occasional burping, or belching, is normal, especially during or after meals. Everyone swallows air throughout the day.

If you swallow too much at once, it may create discomfort and cause you to burp, explains William Ravich, MD, a Yale Medicine GI physician and specialist in swallowing disorders and esophageal disease.

“We swallow air all the time. Every time you eat something, 50% of what you swallow is food and 50% is air [which contains gases like nitrogen and oxygen].

You also swallow when you’re not eating and if you look at your saliva, most of the stuff you might spit out is all bubbles from air,” Dr. Ravich says.

But people have different capacities to tolerate swallowed air, Dr. Ravich says. There is a threshold where the air needs to be released, which is what causes you to burp.

“Some people may reach that threshold quicker. When that threshold is reached, it causes them to belch,” he explains.

Plus, eating too quickly, talking while you eat, chewing gum, and drinking carbonated beverages can all cause you to swallow more air and burp.

But is burping a problem? “In some cultures, belching is considered a sign of appreciation. But in Western society, it is often considered rude,” Dr. Ravich notes.

“I think it’s good to release gas if it’s causing you discomfort. But if you don’t, the gas will also eventually work its way out.”

Gas, of course, can work its way out your other end, too. Flatulence is a normal way of releasing gas from digestion. It can either be foul-smelling or odorless, and both are normal and can be caused by certain foods or medications.

However, smelly gas can sometimes indicate underlying digestive problems or infections. If you are also experiencing severe cramps or abdominal pain, bloating, nausea, vomiting, diarrhea, or bloody stools, contact your doctor.

In fact, remember to not be shy or ashamed about talking to your medical provider about any digestive issue.

Written by Carrie MacMillan.

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