Q&A with Dr Sarah Brewer

Sarah BrewerDr Sarah Brewer is a GP, nutrition expert, health journalist and author. In March 2010, you plied her with questions about all things digestive, and here are her answers.

IBS | Constipation | Coeliac disease | Changes in bowel habits | 'Good' bacteria | Lactose intolerance | Wind and gut rumblings

SarahBrewer: Thank you for trusting me to answer your bowel health queries. Not surprisingly, many of the questions are very similar - the bowels can only 'complain' in a limited number of ways when something is wrong. I have tried to give advice that is as useful as possible, but please bear in mind that any recurrent problems, especially a change in bowel habit, needs to be checked by your own doctor.

 

Irritable bowel syndrome

Q. Coldhands: I was diagnosed with IBS a few years ago and only recently tested for coeliac disease but nothing else has even been considered. Is this normal, as I'm not convinced it is just IBS. I get agonising pains, go to the toilet very quickly and can be on and off all evening. Stomach then feels very sore and tender. I often bleed from the back, which clears up itself then starts again a while later. My stomach always makes very loud noises, which is really embarrassing as the whole room will notice.

A. SarahBrewer: Several bowel conditions can cause similar symptoms, including coeliac disease, lactose intolerance, diverticular disease, intestinal infections and irritable bowel syndrome. Do see your doctor again, and don't be afraid to request a second opinion if necessary. Bleeding from the back passage should always be investigated to find out the cause. Although it is often related to 'piles' this cannot be assumed until other causes, such as inflammatory bowel disease or polyps have been ruled out. 

Q. norksinmywaistband: I have been told I have IBS. I urgently have to use the loo every morning for a loose stool and get some bloating, especially in the evenings. My main problem however is travel - if I go more than 20 miles from home my bowels are terrible. Constant diarrhoea until I get home - even if just visiting family. It is a laughing joke that I can't take a change in the water. Is there a logical explanation?

A. SarahBrewer: Some people with IBS have a type known as functional diarrhoea syndrome. This is associated with:

  • Increased frequency of bowel movements
  • Having to rush to the bathroom (urgency)
  • Passing several stools in rapid succession, often in the morning
  • Stools that characteristically become looser and looser throughout the day


People with this form of IBS are frequently left exhausted and tired. The speed with which the bowels have to be opened can also mean people are housebound or unable to travel far.

Management usually involves taking anti-diarrhoea medication such as loperamide to help normalise bowel function. This slows over-activity in the colon so that more fluid is absorbed and helps to return stool passage to normal. Treatment also relieves stomach cramps and feelings of urgency so you can quickly return to a normal life. Your doctor can advise whether treatment is likely to suit you, and how often you should take any prescribed medication. 

Q. elliedodger: I suffer with bloating and constipation due to IBS. Unless I have a stressful event coming up, in which case I have diarrhoea. I know that conventional advice is to increase fibre intake but that just makes my stomach unsettled and bloated. Peppermint tea makes no difference whatsoever. Can you give me any other advice?

A. SarahBrewer: When increasing fibre intake, it is important to increase slowly, and to drink plenty of fluids, otherwise symptoms can get worse. It is also worth trying fibre supplements such as psyllium and flaxseed. Even though peppermint tea may not have worked for you, peppermint oil capsules (which are significantly stronger) are often effective in improving symptoms of irritable bowel syndrome.

Q. NorbertDentressangle: Can IBS give similar symptoms to gall bladder problems ie pain high up under the ribs and around to the mid-back area lasting a day or two and then disappear again for a few months? (No change in bowel habits or irregularities during these episodes or any other time.) If so, how do you go about identifying what triggers it when nothing obvious springs to mind?

A. SarahBrewer: Any recurrent or persistent pain needs to be investigated to find out the cause. The easiest way to tell whether or not you have gallstones is to have an ultrasound of your upper abdomen. Your doctor should be willing to arrange this for you.

If you do have gallstones, then you should follow a low-fat diet, as it is the presence of fat in the upper digestive tract that stimulates contraction of the gall bladder. If your symptoms are related to IBS, the best way to identify dietary triggers is to follow a restricted diet and reintroduce new foods every few days to see which, if any, provoke your symptoms. Avoid suspect foods until symptoms resolve, then reintroduce them again to see if your symptoms return. It is best to follow an Elimination and Challenge diet under the supervision of a dietician or nutritionist experienced in managing food intolerances.
 

Constipation

Q. cocolepew: What's the best thing for constipation? Obviously I'm asking for a friend <ahem>.

A. SarahBrewer: Constipation is usually defined as passing bowel motions less than twice a week, or straining at stool for more than 25% of the time. It is usually linked with slow movement of digestive contents through the bowel. Although laxatives are available, it is best not to rely on them too often as constipation can get worse if the bowel comes to rely on them. Eat a high-fibre diet containing plenty of fresh fruit, vegetables, salad and pulses (eg peas, beans, lentils, chick-peas).

Dried fruits (especially prunes and figs), seeds (especially sunflower, pumpkin, fenugreek, fennel and linseed) and molasses also have a natural laxative action. Eat more wholegrain cereals: oats, brown rice, wholewheat pasta, wholegrain bread, whole rye, buckwheat, millet, bulgar wheat and couscous.

Drink plenty of fluids, especially water and herbal teas, as dehydration can make constipation worse. Aim to drink one glass (350ml) water before each meal, plus another two or three between meals to bulk up your fibre-rich diet. Probiotic yoghurts can also help.

Q. Saladdays: My daughter has times of constipation that when she poos they are as wide as her calf. She cries, I wince. Any advice? This seems to coincide with teething. I've been having twitching in my bowels that feels like a baby kicking - but I'm not pregnant. Weird. Any ideas what it is?

A. SarahBrewer: It is important to have your daughter checked by your doctor who can advise whether or not she needs any investigations or treatments. A twitching sensation in the abdomen can be due to 'writhing' or spasm of the intestines. Again, it is important to see your doctor who can examine your tummy and check that all feels normal.
 

Coeliac disease

Q. FabIsDoingPrettyWell: I have been tested for coeliac disease and it was negative. Months ago the GP suggested IBS. My problem is if I eat toast for breakfast pretty much straight away I need to use the bathroom. Yesterday I had a homemade cheese tart and same thing. I look pregnant but I am 2st overweight. Just fed up with it all.

A. SarahBrewer: Coeliac disease is caused by a sensitivity to a protein fragment (gliadin, which forms part of gluten) that is found in several cereals including wheat. It is possible to have a sensitivity to wheat proteins other than gluten, however. Some people with IBS find their symptoms become worse when eating wheat or wheat bran products, and that when wheat is eliminated from their diet, symptoms improve. It is worth excluding wheat from your diet for a month to see if this helps.

If it does, you will need to seek advice from a dietician to ensure that you obtain all the nutrients you need while following a wheat-free regime long-term. Check food labels carefully to look for hidden gluten as wheat is often present in products such as soups, stock-cubes and dessert mixes. Avoid foods containing: Flour starch, Edible starch, Modified starch, Wheat starch, Wheat flour, Cereal filler, Cereal binder, Cereal protein or Vegetable protein. More information is available in my book The IBS Diet (Thorsons £6.99), which includes recipes by Michelle Berriedale-Johnson.

Q. shhkeepitquiet: My husband was diagnosed coeliac since a young baby (18 months). Apart from a couple of years in his teens (he is now in his 40s) he is very vigilant re his diet. However, his bowel habit is quite inconvenient and embarrassing at times. In the morning he needs to use the loo around twice on a "normal" day.

If we are on holiday, or he has eaten a large (gluten-free breakfast) he will rush to the loo maybe three to four times. Then through the course of the morning and again after lunch he often has the urgency and need to go often several more times. He has been checked out by a gastroenterologist and nothing abnormal was found. I think part (but not all) is slightly due to anxiety, ie on occasion he has unfortunately had accidents and understandably this make him feel the urgency even more. I have suggested that at real times of pressure (eg if on holiday and going out for the morning) he could take Imodium or equivalent - would this be OK?

A. SarahBrewer: Only his doctor can advise on whether or not anti-diarrhoeal medicine is suitable for him. The most likely cause of these symptoms, however, is the presence of 'hidden' sources of gliadin (a protein fragment that forms part of gluten) to which people with coeliac disease are sensitive. These may be identified on food labels as: Flour starch, Edible starch, Modified starch, Wheat starch, Wheat flour, Cereal filler, Cereal binder, Cereal protein or Vegetable protein, for example.

You can speak to a dietician at Coeliac UK by phoning their Helpline on 0845 305 2060. You will also find it helpful to read The Best Gluten-Free, Wheat-free and Dairy-free Recipes by Grace Cheetham (Duncan Baird, £14.99), which contains over 100 recipes for all the family.
 

Changes in bowel habits

Q. Miggsie: I have a lot of gut problems that started recently. I used to be a regular for bowel movements, once a day in the morning. But now I go four or five times a day. Nothing particularly wrong with the actual motion, but it is so more frequent.

Second, often at night I feel like I really really want to do a poo, but I do not need to, but it still feels like I do. I am also feeling nauseous for a lot of the time, today I am not even eating as the thought of food is making me feel quite ill. I am not pregnant, but it really feels like something is pressing on my bowel and stomach all the time. My gut is making lots of gurgling noises and I am burping a lot as well.
I have tried various things such an antacids and plant extracts for bowel movement but I can't honestly say I notice any difference from when I am taking and when I am not.

A. SarahBrewer: It is very important that you see your doctor for a full medical assessment. Any change in bowel habit should be investigated without delay. Symptoms such as this should never be ignored. Please make an appointment to see your doctor today. 

Q. lisalisa: For the last six months I have been suffering episodes of extreme pain in my lower abdomen right side only. It is a stabbing pain like a needle going in and feels deep inside. It feels very much like wind and my whole stomach swells up and is very tender. The episodes of pain last about five days and start slowly. By day three, I am bedridden.

The first time this happened I was rushed to hospital in a blue light ambulance as I was crawling the walls with pain. They could find nothing wrong and the pain eventually subsided. It returned again just two weeks ago and I suffered five days of intense pain, which again took me out of my life and into bed with its severity. This time I was tested for ovarian cancer, which thankfully came back negative. I feel this may be diet related and wonder if you had any ideas please? In between pain episodes I am pain free.

A. SarahBrewer: A number of things can cause recurrent pain like this, including irritable bowel syndrome, diverticulitis, intestinal obstruction, gynaelogical conditions, and kidney stones. I've even known gallstones to cause unusual pain felt in the lower rather than the upper abdomen.

It is reassuring to know that all tests so far have been negative, but as it has now happened twice, your doctor should be willing to refer you for further investigations to find out the cause. One of the most common dietary-related causes of pain, wind and swelling is an imbalance of bacteria in the bowel, so you have too many gas-forming bacteria, and too few lactic-acid producing bacteria, which help to keep the 'gas producers' at bay. However, it is important to have other medical causes ruled out first before assuming your symptoms are diet-related.
 

'Good' bacteria

Q. TrillianAstra: Can you explain the difference in activity on 'digestive health' between branded yoghurts and generic live yoghurt?

A. SarahBrewer: Live yoghurts generally contain two bacterial cultures: Lactobacillus bulgaricus and Streptococcus thermophilus. These have been shown to help digest lactose (milk sugar) and may help people with lactose intolerance to tolerate yoghurt as a dairy food.

Q. Maratch: I have been giving my son a probiotic supplement. Is there any evidence that this has benefits for his immune system / digestive health? Or is it just a total waste of money?

A. SarahBrewer: By definition, a 'probiotic' must be beneficial for health. However, some probiotics have more research evidence to confirm their benefits than others. You don't say how old your son is, but probiotic drinks and yoghurt can be given to children after they have been weaned successfully on to cows' milk products.

Q. herbietea: I have IBS. I take a probiotic tablet and drink every day. Is there any evidence that these things work?

A. SarahBrewer: The World Health Organization defines 'probiotics' as 'live micro-organisms which, when administered in adequate amounts, confer a health benefit on the host'. So, by definition, they are beneficial. However, specific strains of probiotic bacteria have specific health benefits and so it's important to read the label to determine if the probiotic product is relevant for you.
 

Lactose intolerance

Q. hobnob57: If children are exposed to foods to which they are intolerant, is it actually harming them? My first daughter seems to have a threshold for dairy, beyond which her face puffs up, her flatulence is embarrassing and the sore tummies begin again. Daughter two seems to be intolerant of several things in my diet (she is breastfed) which I haven't got to the bottom of yet. So is her digestive system being harmed in the meantime if she is gaining weight OK? Her dirty nappies are swimming in mucus.

A. SarahBrewer: Generally speaking, it is reassuring if a child is thriving and putting on weight normally. However, intolerance of dairy products can be a sign of lactose intolerance, which is very common in children. Lactose intolerance occurs when there is insufficient production of an enzyme (lactase) needed to break down lactose (milk sugar). As lactose can't be absorbed, it passes down into the bowel where it is fermented by gas-forming bacteria to produce symptoms of bloating and diarrhoea.

It is also possible to react against proteins in dairy products (milk allergy), although this is less common. Do speak to your health visitor about your children as you are concerned. It is also a good idea to ask your doctor to examine one of the 'mucus' nappies to see if any tests or nutritional advice are necessary. Medical tests can diagnose whether or not someone has lactose intolerance.
 

Wind and gut rumblings

Q. cyb: Sometimes my lower guts, for the want of a better word, make the strangest noises. We're not talking farts but deep, almost mewling sounds that are loud enough to hear by me and those around me. 'Tis quite embarrassing. They do feel like they are coming from quite low down. Any suggestions?

A. SarahBrewer: These rumbling bowel noises are known as 'borborygmi' and are caused by wind burbling around in the bowel. Sometimes it can be associated with pain, distension and flatulence. Most intestinal gas comes from bacteria fermenting indigestible fibre and starches to release gases such as hydrogen, carbon dioxide, methane and sometimes foul-smelling sulphurous gases.

These gases are not absorbed to any great extent and are expelled - most people pass between one and two and a half litres of gas per day! To reduce rumbling noises, eat regular meals and avoid 'windy' foods that promote bacterial fermentation such as beans, lentils, cauliflower, cabbage, broccoli, Brussel sprouts and cucumber. Probiotic yoghurts contain strains of bacteria that discourage the growth of less beneficial 'gas-forming' bacteria.

Q. posieparkerfuckityfuck: A member of my family is very stinky - terrible smelly blow-offs and poo that, quite frankly, fills the whole house with its toxic odour. I think this is due to rotten guts through years of drinking too much. Am I right? What can be done?

A. SarahBrewer: It is a good idea to suggest your loved one sees their doctor for a full medical check-up. If they have a history of drinking heavily, a liver check is also important.

Q. emmap: I get bloated every afternoon after lunch. It doesn't matter what I eat, whether I eat quickly, slowly etc. The next phase - ie, release of bloating, windy-style - are fairly high powered. Why the bloating?

A. SarahBrewer: It is difficult to know why this is happening, but increasing bloating as the day goes on is relatively common in women. It may be related to reduced muscle tone in the small bowel, as part of a variant of irritable bowel syndrome known as primary foregut motility disorder. However, symptoms such as this should not be ignored, and it is important to seek individual medical advice from your own doctor.

Last updated: 15-Oct-2013 at 5:03 PM