One of the most common reasons for referral to a gastroenterologist is the feeling of bloating (abdominal distension). It occurs when gas or fluid accumulate in the abdomen, causing expansion of the small or large intestine. In younger people it is usually a benign and harmless, albeit distressing, symptom but rarely it may be due to an underlying disease.

Bloating is most commonly a feature of irritable bowel syndrome (IBS) but the following conditions may cause bloating and need to be considered:

And more rarely:

  • Abnormal fluid accumulation (ascites)
  • Large ovarian cyst or uterine fibroid (noncancerous growths of the uterus)

Investigation of Bloating

The cause of bloating may be clear following a careful history and examination by a doctor. The following tests may be undertaken to help with the diagnosis:

  • Blood test to look for coeliac disease
  • Stool sample to look for Giardia lambliaantigen
  • Hydrogen breath tests for carbohydrate intolerances or small intestinal bacterial overgrowth
  • Faecal calprotectin to exclude inflammation or infection
  • Ultrasound scanning of the abdomen and pelvis (in a female) to exclude abnormal fluid accumulation or enlarged organs

Treatment of Bloating

This will depend upon the underlying cause. Thus, infection with G lambliais cured by tinidazole. Lactose or fructose intolerance may respond to dietary restriction. Small intestinal bacterial overgrowth may be helped by an antibiotic (e.g. rifamixin) or probiotics. IBS with bloating is often relieved by  a low FODMAP diet (avoiding foods rich in short chain carbohydrates that are poorly absorbed in the small intestine and so are rapidly fermented by bacteria in the colon). In patients with a new diagnosis of coeliac disease, a gluten-free diet will need to be followed.

For more information about bloating and potential treatment options, please do not hesitate to contact Dr. Adam Harris.

Irritable Bowel Syndrome (IBS) affects up to 20% of the UK population with women at least twice as likely to be affected as men. Common symptoms include bloating, constipation, diarrhoea and abdominal discomfort.While many help their symptoms by changing diet such as avoiding foods high in FODMAPS, this blog will examine the positive effects that probiotics may have on IBS by modifying the balance, or biodiversity, of the gut bacteria or microbiome. Probiotics are defined as “live microorganisms, which, when administered in adequate amounts, confer a health benefit on the host.”

So, how may a probiotic help to reduce IBS symptoms?

  1. Probiotics may give a boost to the numbers of “friendly bacteria” in the gut. There is some evidence, albeit limited, that the bacterial biodiversity may be altered in individuals with IBS.
  2. An improvement in “friendly bacteria” may help to break down the FODMAPS foods that may exacerbate IBS.
  3. A change in the biodiversity of the gut microbiome may also play a role in modulating the gut’s nervous system, thus reducing the impact of stress on the gut.

Here, I mention 3 probiotics that, to the best of my knowledge, were shown in clinical trials to be significantly better than placebo at relieving symptoms in individuals with IBS.

Symprove is a water-based probiotic that contains four live strains of the ‘friendly bacteria’ lactobacillus available from the internet or directly from the manufacturer. About 70mls of Symprove is drunk at the start of the day, 10 minutes before eating or drinking anything, for 12 weeks. Once a bottle is opened it must be stored in a fridge.

It was shown in a large clinical trial to help IBS. Researchers at London’s King’s College Hospital found that more individuals with moderate-severe IBS achieved remission after a 12 weeks course of Symprove than those taking placebo (an identical looking and tasting supplement but one which didn’t contain any bacteria).

Bio-Kult contains a total of 14 different strains of 5 different bacteria and a minimum of 2 billion live bacteria per capsule. It is taken once or twice daily for at least 28 days and if of benefit, may be used long term. Bio-Kult does not need to be stored in a fridge, is stable at room temperature and has a long shelf-life. The capsules were shown in the laboratory to resist acid or up to 2 hours implying they should survive the acidic environment of the human stomach. A randomized, controlled trial in India found that Bio-Kult was significantly more effective than placebo in individuals with IBS with diarrhoea.

Alflorex, a single strain (Bifidobacterium infantis3564) probiotic is taken once daily in capsule form for a minimum of 28 days.  A single Alflorex capsule contains around 1 billion live bacteria. It was shown to be significantly better than placebo in a large study in women with IBS.

For more information about these treatment options, please do not hesitate to contact Dr. Adam Harris.

A healthy liver should contain little to no fat. Having high levels of fat in the liver is associated with an increased risk of serious health problems, from diabetes and high blood pressure to kidney disease. This month’s blog will discuss non-alcoholic fatty liver disease (NAFLD), the term used for excess fat build-up in the liver. As highlighted in the name, this condition isn’t caused by drinking too much alcohol.

It’s important to detect and manage this condition as early as possible – Stage 1 NAFLD doesn’t usually cause any serious harm but if it the fat build-up continues, it can lead to serious liver damage including cirrhosis.

There are 4 stages of NAFLD:

  • simple fatty liver (hepatic steatosis) – most common stage that may affect 1 in 3 adults in the UK
  • non-alcoholic steatohepatitis (NASH) – a more serious form where the liver has become inflamed, estimated to effect up to 5% of the UK adult population
  • fibrosis –where persistent inflammation causes scarring, but the liver is still able to function normally
  • cirrhosis – the most severe stage which occurs after many years of inflammation. The damage is permanent and can lead to liver failure and liver cancer

Individuals are at an increased risk of developing NAFLD if they:

  • are obese or overweight
  • have type-2 diabetes
  • have high blood pressure & cholesterol
  • are over the age of 50
  • smoke cigarettes

There aren’t usually any symptoms of the condition in the early stages – it is usually diagnosed following an abnormal result from a liver function test (raised GGT and/or ALT; high ferritin) or after an ultrasound scan. Occasionally, a liver Fibroscan or even a biopsy may be required to establish the stage of the disease.

How is NAFLD treated? While there’s currently no specific medication for the condition, the best management is to lose weight, eat a healthy balanced diet & exercise regularly.

If you have any questions about non-alcoholic fatty liver disease, please do not hesitate to contact Dr. Harris.

The low FODMAP diet is a relatively new concept in the UK.  It is recognised by NICE as an effective diet for managing the symptoms of IBS such as abdominal pain, wind and bloating. About 70% of people with IBS who try the diet will achieve an improvement in their gut symptoms.FODMAPS are found in a wide range of foods including: onion, garlic, wheat, lactose, honey, nuts and many fruits and vegetables (apples, pears, broccoli and avocado to name but a few).

Once ingested, some FODMAPs are not absorbed in the small intestine and cause osmotic diarrhoea.  As they pass into the large intestine they are fermented by colonic bacteria which may result in gas production and symptoms such as wind, pain and bloating.

Reducing dietary intake of FODMAPS has been shown to improve gut symptoms in most people with functional bowel disorders such as irritable bowel syndrome (IBS).

The low FODMAP diet is a complex approach however and involves a 4-8 week period of restricting FODMAP rich foods. This is followed by the systematic reintroduction of these foods back into the diet. The purpose of this stage is to identify foods that trigger symptoms and ensure a nutritionally balanced diet at the end of the process.

It is important that people who undertake the diet receive good quality advice from a Registered Dietitian on how to follow the different stages of the low FODMAP diet. It isn’t as simple as following a list of ‘foods to eat’ and ‘foods not to eat’. High FODMAP ingredients are often hidden in processed foods. Because the diet is relatively new, the information available on the internet and elsewhere can be misleading and create confusion.

An important point of note is that if the diet isn’t followed properly, it’s unlikely to be effective.

For more information please contact Ali Todd, Registered Dietitian, on 07810 367549 or for an appointment 07757 757571. In addition, further information is available on her website.

What is it?

  • Colonic diverticulosis is the condition whereby diverticula, or pockets, form from the lining of the colon. These protrusions of the colon lining occur at sites of weakness in the muscle wall possibly due to increased pressure from muscle contractions.
  • Diverticulitis is an inflammatory process that causes acute symptoms and may be associated with serious complications.

What may cause it?

  • Potential risk factors include increasing age; diets low in fibre, high in red meat and refined carbohydrates; obesity.
  • There is no evidence that seeds or nuts cause diverticulitis.
  • Changes in the biodiversity of the colonic bacteria

What are the symptoms?

  • Diverticulosis is often asymptomatic and found on investigation by colonoscopy or CT scanning. It may be associated with low abdominal cramping, bloating or constipation.
  • Diverticulitis, due to infection or inflammation of the diverticula, may cause localized lower left sided abdominal pain with either diarrhoea or constipation and fever. Bleeding may occur.

How common is it?

  • Classically, this is a disease process that predominantly affects people over the age of 70 years and is more common in developed countries. It is however getting more common in younger people possibly related to obesity.

What tests are needed to diagnose it?

  • A colonoscopy enables the gastroenterologist to examine the lining of the colon to confirm diverticulosis and to exclude colon cancer or inflammatory bowel disease.
  • An abdominal CT scan is a radiological test used to diagnose diverticulitis and to look for complications.
  • A blood test may be performed to look for any signs of infection or inflammation within the colon.

How do you treat it?

  • Individuals with diverticulosis are advised to eat a healthy and balanced diet, avoid too much red meat and to lose weight if obese. Use of a prebiotic and/or a probiotic may be of benefit but at present this is an evidence-free zone.
  • Mild diverticulitis is usually treated with oral antibiotics. A recent placebo-controlled trial however did not show, in the outpatient setting, that antibiotics were any better than placebo.
  • Patients with complications of acute severe diverticulitis such as an abscess (collection of pus) or perforation (a hole in the colon) require emergency admission to hospital for intravenous antibiotics and sometimes urgent surgery.
  • Long-standing severe diverticulosis or following recurrent attacks of diverticulitis the colon may get narrowed (stricture formation) and surgery may be required to avoid obstruction.

If you have any questions, please do not hesitate to contact Dr. Harris.

Rifaximin is an antibiotic that can be used to treat irritable bowel syndrome without constipation (IBS) and small intestinal bacterial overgrowth (SIBO) and if successful, may relief abdominal pain, bloating and diarrhoea. Individuals with IBS and/or SIBO are thought to have abnormal biodiversity of the gut microbiome. The overgrowth of gut bacteria may lead to excessive gas production and malabsorption of certain carbohydrates (see last month’s blog) leading to symptoms, such as diarrhoea, gas bloating and abdominal pain. Rifaximin may improve the biodiversity and thus improve symptoms.It’s worth noting that the rifaximin is usually well-tolerated and has few side effects, predominantly because less than 0.5% of the oral dose is absorbed from the gut. However, patients may still experience mild symptoms such as nausea, dizziness and fatigue. The drug does not appear to lead to bacterial resistance nor an increase in risk of Clostridium difficile infection (a concern when using broad-spectrum antibiotics).

If used to treat SIBO repeated courses may be required if symptoms return. Recurrence of SIBO may occur after rifaximin treatment in around 15% of patients at 3 months, 30% of patients at 6 months and 40% of patients at 9 months. If this is confirmed by a lactulose hydrogen breath test, further treatment may be required.

Rifaximin comes in tablet form (400mg) and is usually taken 3 times daily for 10 days. It can be taken with or without food. However, the high cost of rifaximin has limited its use; it is not a treatment option as an NHS patient.

If you have any questions about rifaximin or the treatment of IBS or SIBO, please do not hesitate to contact Dr. Harris.

Carbohydrates are commonly consumed as part of a typical Western diet. This blog will highlight some of the problems that carbohydrates may pose if there are problems with digestion or absorption.Carbohydrate digestion starts in the upper part of the small intestine where enzymes (e.g. lactase) break down the larger carbohydrates (polysaccharides or starches) into smaller monosaccharides which are absorbed into the blood stream. If this process is incomplete (maldigestion or malabsorption) excess carbohydrates may reach the colon where fermentation by bacteria can lead to the production of excess gas (hydrogen, carbon dioxide and methane) and fatty acids (butyrate and propionate) leading to abdominal cramps, flatulence, bloating and diarrhoea.

Symptoms related to carbohydrate malabsorption or maldigestion may occur in patients with irritable bowel syndromesmall intestine bacterial overgrowth, coeliac or Crohn’s disease or after surgery or radiotherapy to the gut. In addition, some people may have a relative lack of enzymes, such as lactase or fructase, leading to an inability to breakdown and absorb lactose- or fructose-containing foods such as dairy products or fruits.

Carbohydrate malabsorption or maldigestion may be suspected during consultation with a gastroenterologist or dietician. Hydrogen breath tests may be undertaken to confirm lactose intolerance or fructose intolerance. If confirmed, symptoms may be helped by reducing lactose or fructose containing food items. A lactulose hydrogen breath test may be performed to look for SIBO and if abnormal, individuals may respond to dietary changes, an antibiotic or probiotic.

The link between ingested carbohydrates and IBS was identified some years ago by Australian doctors who developed the low FODMAP diet whereby fermentable oligosaccharides, disaccharides, monosaccharides and polyols are reduced or eliminated from the diet. These carbohydrates include fructose (found in certain fruits like apples, mangoes, watermelon and dried fruits), lactose (found in milk and milk products), fructans (found in wheat, garlic and onions), galactans (found in legumes) and polyols (found in fruits such as peaches and certain vegetables such as mushrooms and cauliflower). The low FODMAP diet is challenging to follow and ideally should be supervised by a dietician.

In summary, in individuals with symptoms related to ingestion of carbohydrates, assessment by a gastroenterologist or dietician, hydrogen breath testing and dietary manipulation may be of benefit.

If you have any questions about carbohydrates and maldigestion, please do not hesitate to contact Dr. Harris.

Studies conducted in recent years have explored the relationship between the gut microbiota, consisting of around 800 different bacteria species, and metabolism. It has been suggested that specific intestinal microbial compositions can either protect from, or contribute to, obesity and other metabolic diseases.

First, I would like to discuss short-chain fatty acids (SCFA) and the vital role they play in influencing gut health. SCFA are produced by bacteria from fermentation of dietary products, mostly fibre, within the colon. Their primary role is to serve as a source of energy for cells within the colon and to stimulate repair and replacement. Of potential interest, butyrate may influence how energy (including glucose) is metabolised in the body and so hold a possible protective effect against metabolic disease and obesity.

The potential relationship between gut microbiota and obesity was analysed in this excellent 2017 study when faecal microbiota from both lean and obese subjects was transferred into mice, which then changed their feeding behaviour and subsequently their body mass to reflect the human source. The researchers suggested that butyrate positively influences energy balance and thus protects from diet-induced obesity.

Subsequent research has shown a broad variety of possible effects of butyrate on metabolism including an increase in mitochondrial activity, preventing metabolic endotoxemia, improving insulin sensitivity, increasing intestinal barrier function and protecting against diet-induced obesity.

These fascinating findings suggest a relationship between the gut microbiota and human metabolism. Further research is needed in humans to extend the experimental findings in mice and to establish if the gut microbiome may be changed (by prebiotics, probiotics, antibiotics or even faecal transplantation) to help reduce obesity and even, diabetes.

If you have any questions about gut microbiota and its relationship to obesity, please do not hesitate to contact Dr. Harris

In the 19th edition of the Gut Reaction series, I suggested that patients with Laryngo-Pharyngeal Reflux (LPR) may consider an alkaline water & plant-based Mediterranean style diet. As discussed in that blog, a paper published in JAMA Otolaryngology (October 2017) suggested that diet and consumption of alkaline water might be as effective as treatment with a PPI. The main outcome of the study was a change in Reflux Symptom Index (RSI) – the 1st group were treated with PPI and standard anti-reflux precautions (PS) and the 2nd group with alkaline water, a plant-based Mediterranean-style diet and standard anti-reflux precautions (AMS). Results from the study showed that the percentage of patients achieving a clinically meaningful reduction in RSI was 54% in PS-treated patients and 63% in AMS-treated patients.

How alkaline water and dietary change help the symptoms of LPR is unclear but it may change the biodiversity of the gut bacteria (microbiome) in the oro-pharynx, gullet (oesophagus) and stomach.

In this blog, I will provide some further information regarding alkaline water and what the Mediterranean-style diet involves.

First of all, the “alkaline” in alkaline water refers to its pH level. The pH level is a number that measures how acidic or alkaline a substance is on a scale of 0 to 14. Alkaline water has a higher pH level than regular drinking water. Because of this, some advocates of alkaline water believe it can help maintain balance by neutralising the acid in your body. Drinking water generally has a neutral pH of 7 while alkaline water typically has a pH 8-9.

It is relatively straightforward to make your own alkaline water at home. Here is a suggested recipe:

  • Pour a half-gallon of the filtered water (preferable to tap water) into a gallon jug with a lid. If using tap water, a filtration system is recommended.
  • Add one teaspoon each of baking soda, sea salt and coral calcium powder to the container.
  • Wash a lemon and slice it in half. Squeeze the juice into a small bowl.
  • Pour the juice into the water/baking soda/coral calcium mix.
  • Secure the container lid and then shake it vigorously to thoroughly mix all the ingredients.
  • Add the rest of the distilled water to the container, being sure to leave an inch of space at the top of the container for air.
  • Close the container tightly and shake it to mix the water.
  • Use pH strips to test the water to see the level, ideally around level 8 or 9. If that is not the case, add another ¼ teaspoon of baking soda and mix again until the proper pH level is reached.

Equally, many supermarkets stock alkaline water along with other specialty waters in the bottle water aisle. It can also be ordered online from a number of retailers.

Here is some basic information about the plant-based Mediterranean style diet:

  • Eating primarily plant-based foods, such as fruits and vegetables, whole grains, legumes and nuts.
  • Replace butter and other dairy with healthy fats such as olive oil and canola oil.
  • Use herbs and spices instead of salt to flavour foods.
  • Limit red meat to consume no more than a few times a month.
  • Eat fish and poultry at least twice a week.

If you have any questions about alkaline water or a plant-based Mediterranean style diet, please do not hesitate to contact Dr. Harris.

This month’s blog will focus on STW5 (or Iberogast), a herbal product used for many years to treat functional dyspepsia (a chronic disorder of sensation and movement in the upper digestive tract – read more here).

What is it?

Iberogast is a liquid formulation of nine herbs, developed in Germany in 1961 and named after the genus (Iberis) of one of its ingredients. It consists of a mixture of extracts from bitter candytuft, angelica root, milk thistle fruit, celandine herb, caraway fruit, liquorice root, peppermint herb, balm leaf and chamomile flower.  It contains no sugar, salt, yeast, wheat, gluten, corn, soy, dairy products, artificial colouring, artificial flavouring, or preservatives but does contain a small amount of alcohol.

Is it safe?

Used throughout Europe and other parts of the world for more than forty years, Iberogast has been used by over 20,000,000 patients with only 18 reported adverse events over the years. It appears therefore safe to use.

How does it work?

It is thought to affect various different functional processes in a complimentary, synergistic way. Thus it has been shown to affect the movement and tone of the stomach; alter the mucus lining the stomach; help reduce gas formation; decrease sensitivity to pain and possibly alter the gut microbiome.

Does it work?

A recent study found that patients with functional dyspepsia taking Iberogast had significantly reduced gastrointestinal symptoms compared to the control group who were taking placebo. Of patients taking Iberogast, 86% reported a therapeutic effect after four weeks of treatment. Results from a meta-analysis in 2013, which combined data from multiple, varied, small trials performed over the past decade, reinforced these findings of significantly more effectiveness than placebo in providing symptomatic relief to patients with functional dyspepsia. The researchers compiling the data agreed that although the cumulative total of patients in this meta-analysis was relatively limited, it was still large enough to demonstrate efficacy, even though they did suggest more research.

How it is taken?

Each Iberogast bottle has a built-in drop dispenser – shake the bottle before use, hold the bottle at a 45 degree angle and shake the required number of drops into a small glass of water (or liquid of your choice e.g. juice or warm tea) and drink, 3 times a day.

The recommended dose of Iberogast is 20 drops (1 mL), 3 times a day.

Where can I get some?

Iberogast can be bought over the counter at your local Health Food shop or online.

At West Kent Gastroenterology, we work hard to provide our patients with top-class care. You will enjoy friendly, fast and modern treatment by a highly experienced gastroenterologist. We carefully review patient satisfaction and feedback, and at West Kent Gastroenterology we are continuously making improvements to our services, ensuring the highest level of care possible.

Clinic Locations

Nuffield Hospital
Kingswood Road, Tunbridge Wells, TN2 4UL

Spire Hospital
Fordcombe Road, Tunbridge Wells, Kent, TN3 0RD

Sevenoaks Medical Centre
London Road, Sevenoaks, Kent, TN13 2JD


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