What’s wrong with my gut? – a Guide for Nausea and Gastroparesis

How is your gut health?

Unfortunately, many people go their whole life not realizing that they are living in a fog. Operating at 70% is a new normal. There may be glimpses of increased energy, better mental clarity, and improved physical vitality, but these episodes seem to be short-lived.

What you may not know is that a state of sub-optimal gut health may be a main driver of why you don’t feel your best. Your gut has a far-reaching impact on your entire body’s physiology and function. From your brain chemistry, to your joint health, skin complexion, and mental acuity, your gut health dictates a lot of your overall health.

In this article, we are going to unpack what may be causing some common symptoms of an imbalanced gut. Perhaps you (or someone you know) are suffering from nausea, bloating, belching, pain in your upper part of your abdomen, and maybe even vomiting. These are all characteristic of a condition called gastroparesis.

A consensus of 40 GI experts state that gastroparesis is a result of delayed stomach emptying absent of mechanical blockage. [1] If you have low thyroid function, a history of bariatric surgery, have diabetes, or have had an short-lived stomach infection, then you may be at higher risk of having gastroparesis.

This can be a frustratingly difficult condition to diagnose and treat, and many patients suffer (an unnecessarily) long-time with these symptoms before finding an answer to their condition.

Fortunately though, there is new and exciting evidence that points us to:

1. A possible root cause of gastroparesis and associated symptoms
2. Multiple novel strategies to remediate this root cause

In this article, I will walk you through a tour of how you can solve these symptoms and eliminate the frustration and confusion that they may have led to in your current state of health.

An overgrowth of bacteria may lead to gastroparesis

It may be no surprise that our body’s actually harbor more live microbial cells than human cells. We have a plethora of bacteria, viruses, parasites, fungi, and even amoebas that call our gut home. Collectively, it’s called the “microbiome”.

Under normal conditions, most of the microbiome is isolated to your large intestine. Our small intestine, on the other hand, has only small amounts of microbes. However, there are times when the small intestine can become overrun with bacteria and other microbes. The name given to this situation is appropriately called “small intestinal bacterial overgrowth” or “SIBO” for short.

This imbalanced microbiome environment can ultimately contribute to symptoms associated with gastroparesis (nausea, reflux, bloating, belching, etc.).

In a study of 50 patients with gastroparesis, SIBO was found in 60% of individuals. [2] Furthermore, SIBO was more likely the longer the patient had gastroparesis. Another study suggested that up to 39% of 700 gastroparesis patients also had SIBO. [3] This association may be secondary to slowed gut motility that sets up a conducive environment for bacterial overgrowth. [4]

However, it’s important to note that not all data agrees. In another study of 73 participants, there was NO association between the diagnosis of SIBO and delayed gastric emptying. [5] Even though delayed gastric emptying is associated with the diagnosis of gastroparesis, this study did not look at the direct relationship between SIBO and gastroparesis. This study also used a different method for diagnosing SIBO (culture) as compared to the first study (breath testing).

In summary, it looks like SIBO may be associated and possibly contribute to gastroparesis but we don’t have a ton of research on this topic and more evidence is certainly needed.

SIBO is associated with Irritable Bowel Syndrome (IBS)

The next step in line for identifying possible solutions to gastroparesis and its symptoms is to acknowledge the association of SIBO and IBS.

Just like IBS, the symptoms associated with SIBO include abdominal discomfort, diarrhea and/or constipation, gas, and bloating. [6]

SIBO is just one of many causes of IBS. With that said, SIBO comprises a large portion of IBS cases. Specifically, in a meta-analysis of 50 studies, more than ⅓ of IBS patients tested positive for SIBO. [7] Furthermore, IBS patients are 5x more likely to have SIBO compared to healthy controls. [7] This evidence points to the strong relationship with SIBO and IBS.

IBS therapies may also help gastroparesis

Some of these symptoms of SIBO and IBS also overlap with those of gastroparesis. Since we have a multitude of data points of successful therapies for SIBO, we may extrapolate that to suggest these therapies may also be helpful for gastroparesis as well.

Let’s take a closer look at some of these.

A Low FODMAP diet helps treat SIBO and IBS

Some types of food contain fermentable fiber (FODMAPs) that can feed bacterial imbalances in the gut. A low FODMAP diet reduces digestible fiber in the diet that can feed the overgrowth of bacteria associated with IBS and SIBO.

Many professional organizations endorse the use of a low FODMAP diet for SIBO and IBS. [8] In a randomized controlled trial, 68% of those with IBS symptoms reported adequate control of symptoms after 4 weeks of a low FODMAP diet. [9] A meta-analysis determined that the low FODMAP diet reduced overall digestive symptoms and abdominal pain, and increased quality of life. [10] A second meta-analysis came to a similar conclusion. [11]

A low FODMAP diet may also help gastroparesis

In a study of 45 gastroparesis patients, foods that worsen symptoms include some higher FODMAP foods (e.g. broccoli, onions, cabbage). [12] Furthermore, foods that improved symptoms included low FODMAP foods. While more research needs to be performed, this current data suggests that a low FODMAP diet may be a good starting point for someone with reflux, nausea, and gastroparesis.

Probiotics are effective for SIBO/IBS, and possibly gastroparesis

Do probiotics even work?

Unfortunately, probiotics have not enjoyed the merit and credit that they deserve. Too many health pundits and even clinicians are doubting the efficacy of this therapy.

When we examine the research, we come across a multitude of studies on probiotics. In fact, there are over 2,600 trials looking at probiotics use in IBS patients. Let’s look at some of the evidence to show my point.

In a meta-analysis, the results of 20 placebo-controlled clinical trials were reviewed with a total of 1,400 subjects. [13] The probiotic group showed improvement in global IBS symptoms when compared to the placebo group. This includes improvements in:

• Constipation
• Diarrhea
• Abdominal pain
• Bloating
• Gas
• Food intolerance
• Fatigue

Also, many professional gastrointestinal medical organizations endorse the use of probiotics in IBS:

• Canadian Association of Gastroenterology
• Romanian Guidelines for Nonpharmacological Therapy of IBS
• American College of Gastroenterology Monograph on Management of Irritable Bowel Syndrome

Many more meta-analysis and clinical trials support the use of probiotics in IBS. [13,14,15,16,17,18,19]

To further my point, probiotics have shown to work better if a patient has both IBS and SIBO, compared to IBS without SIBO. [20]

Probiotics may be useful in those with gastroparesis. This postulation is made on the fact that some studies using probiotics in those who are constipated showed faster gut transit time. For example, a meta-analysis of 17 studies and 1,500 patients, suggested that patients using probiotics experienced a shorter gut transit time by 12.36 hours compared to placebo. [21]

Nonetheless, not all studies show beneficial effects of probiotics and some studies are limited in small sample sizes. However, the majority of evidence supports a trial of probiotics for many functional gastrointestinal disorders including gastroparesis.

An elemental diet is effective for SIBO/IBS and shows promise for gastroparesis

Think of a time that you strained a muscle or maybe even broke a bone. Perhaps you sprained your ankle while on a run. What would you think if you were to go to your doctor and they told you to “keep on running”? It would be a crazy idea, right?

In the same way we need to give a sprained ankle some rest and T.L.C., we should also give our gut a break from the constant slow drip of solid food that it needs to break apart, digest, and absorb. This is where the elemental diet comes in.

An elemental diet is a liquid diet formula of pre-digested fat, protein and carbohydrates. In other words, it is pre-digested food so your gut can rest and relax while it heals. It also contains all necessary vitamins and minerals to sustain a healthy diet.

It’s been studied heavily in the setting of inflammatory bowel disease and some research has been performed on IBS and SIBO patients.

One study showed that an elemental diet leads to:

• 80% resolution of SIBO
• 65% of participants improved IBS symptoms [22]

Compared to other IBS and SIBO therapies, an elemental diet does not have as much rigorous data to support its efficacy. However, given its safety and practicality, it’s a very viable option for functional gastrointestinal disorders such as gastroparesis.

In one study, 12 patients with gastroparesis were studied on four separate days receiving one of four meals each day in a randomized order: high-fat solid, high-fat liquid, low-fat liquid, and low-fat solid meal. [23] Of the 4 diets studied, the low-fat liquid diet showed the least amount of symptom severity. Another study in the Lancet endorses liquid nutrition in those with gastroparesis. [24]

This suggests a liquid diet formula such as the elemental diet may be an effective therapy for gastroparesis.

Be cautious with medications

Typically, medications are used to control symptoms of gastroparesis in a conventional setting. However, common medications used for this condition may not be that effective and may even be harmful long-term.

Prucalopride is a common medication used to help speed up the gut’s motility system to prevent the symptoms of gastroparesis. In a smaller study of gastroparesis patients, prucalopride had gastric gastric emptying time but NO difference in symptoms when compared to placebo. [25]

Another similar medication used for gastroparesis called metoclopramide has been cautioned not to use more than 12 weeks secondary to its side effects of movement disorders. [1]

While some of these potential risks are not that high, it is still important to note the possible long-term health effects nonetheless.

As a result of some of these cautions, I am more in favor of trying to help my patients:

1. Identify the most upstream root cause of their symptoms (instead of just controlling symptoms)
2. Use more natural therapies to find lasting solutions to their health concerns

The Bottom Line

Gastroparesis shares some characteristics of SIBO and IBS and there is a higher rate of SIBO in those with gastroparesis.

Even though some of these treatment strategies have not been used in studies looking specifically at those with gastroparesis, these therapeutics are very effective for the symptoms associated with gastroparesis.

Given the small amount of conventional therapies for those with gastroparesis that can be used long-term, I am in favor of pursuing other evidence-based and practical therapeutics shown to be effective for related disorders such as SIBO and IBS.

If used in a comprehensive and personalized manner, these therapies could very well mitigate and even reverse gastroparesis. This is exactly what I do at at our clinic.

If you want to learn more about minimally-invasive ways to heal your gut, then download the “Gut Reset Guide”. 

If you or someone you know is suffering with bad gut health, then schedule an appointment with me today to see how I can help you eliminate the guesswork and find lasting solutions to your health. I hope you found this information useful and helpful in your journey back to a healthier and happier life.

References

1. Schol J, Wauters L, Dickman R, Drug V, Mulak A, Serra J, Enck P, Tack J; ESNM Gastroparesis Consensus Group. United European Gastroenterology (UEG) and European Society for Neurogastroenterology and Motility (ESNM) consensus on gastroparesis. Neurogastroenterol Motil. 2021 Aug;33(8):e14237. doi: 10.1111/nmo.14237. PMID: 34399024.
2. Reddymasu SC, McCallum RW. Small intestinal bacterial overgrowth in gastroparesis: are there any predictors? J Clin Gastroenterol. 2010 Jan;44(1):e8-13. doi: 10.1097/MCG.0b013e3181aec746. PMID: 20027008.
3. George NS, Sankineni A, Parkman HP. Small intestinal bacterial overgrowth in gastroparesis. Dig Dis Sci. 2014 Mar;59(3):645-52. doi: 10.1007/s10620-012-2426-7. Epub 2012 Oct 5. PMID: 23053897.
4. Dukowicz AC, Lacy BE, Levine GM. Small intestinal bacterial overgrowth: a comprehensive review. Gastroenterol Hepatol (N Y). 2007 Feb;3(2):112-22. PMID: 21960820; PMCID: PMC3099351.
5. Calderon G, Siwiec RM, Bohm ME, Nowak TV, Wo JM, Gupta A, Xu H, Shin A. Delayed Gastric Emptying Is Not Associated with a Microbiological Diagnosis of Small Intestinal Bacterial Overgrowth. Dig Dis Sci. 2021 Jan;66(1):160-166. doi: 10.1007/s10620-020-06153-1. Epub 2020 Mar 2. PMID: 32124195; PMCID: PMC8048091.
6. Takakura W, Pimentel M. Small Intestinal Bacterial Overgrowth and Irritable Bowel Syndrome – An Update. Front Psychiatry. 2020 Jul 10;11:664. doi: 10.3389/fpsyt.2020.00664. PMID: 32754068; PMCID: PMC7366247.
7. Chen B, Kim JJ, Zhang Y, Du L, Dai N. Prevalence and predictors of small intestinal bacterial overgrowth in irritable bowel syndrome: a systematic review and meta-analysis. J Gastroenterol. 2018 Jul;53(7):807-818. doi: 10.1007/s00535-018-1476-9. Epub 2018 May 14. PMID: 29761234.
8. Dumitrascu DL, Baban A, Bancila I, Barboi O, Bataga S, Chira A, Chirila I, Cijevschi Prelipcean C, Ciobanu L, Cozma-Petrut A, David L, Diculescu M, Dobru D, Dimitriu A, Dumitru E, Fadgyas-Stanculete M, Gheorghe C, Gilca-Blanariu GE, Goldis A, Grad S, Macarie M, Marica-Sabo C, Miere D, Nedelcu L, Negovan A, Pojoga C, Pop AV, Popa SL, Porr PJ, Rusu F, Seicean A, Sporea I, Stroie T, Blaga-Surdea T, Tocia C, Trifan A, Brisc C, Drug V. Romanian Guidelines for Nonpharmacological Therapy of IBS. J Gastrointestin Liver Dis. 2021 Jun 18;30(2):291-306. doi: 10.15403/jgld-3581. PMID: 33951120.
9. Staudacher HM, Lomer MC, Anderson JL, Barrett JS, Muir JG, Irving PM, Whelan K. Fermentable carbohydrate restriction reduces luminal bifidobacteria and gastrointestinal symptoms in patients with irritable bowel syndrome. J Nutr. 2012 Aug;142(8):1510-8. doi: 10.3945/jn.112.159285. Epub 2012 Jun 27. PMID: 22739368.
10. Marsh A, Eslick EM, Eslick GD. Does a diet low in FODMAPs reduce symptoms associated with functional gastrointestinal disorders? A comprehensive systematic review and meta-analysis. Eur J Nutr. 2016 Apr;55(3):897-906. doi: 10.1007/s00394-015-0922-1. Epub 2015 May 17. PMID: 25982757.
11. Altobelli E, Del Negro V, Angeletti PM, Latella G. Low-FODMAP Diet Improves Irritable Bowel Syndrome Symptoms: A Meta-Analysis. Nutrients. 2017 Aug 26;9(9):940. doi: 10.3390/nu9090940. PMID: 28846594; PMCID: PMC5622700.
12. Wytiaz V, Homko C, Duffy F, Schey R, Parkman HP. Foods provoking and alleviating symptoms in gastroparesis: patient experiences. Dig Dis Sci. 2015 Apr;60(4):1052-8. doi: 10.1007/s10620-015-3651-7. Epub 2015 Apr 4. PMID: 25840923.
13. McFarland LV, Dublin S. Meta-analysis of probiotics for the treatment of irritable bowel syndrome. World J Gastroenterol. 2008 May 7;14(17):2650-61. doi: 10.3748/wjg.14.2650. PMID: 18461650; PMCID: PMC2709042.
14. Yuan F, Ni H, Asche CV, Kim M, Walayat S, Ren J. Efficacy of Bifidobacterium infantis 35624 in patients with irritable bowel syndrome: a meta-analysis. Curr Med Res Opin. 2017 Jul;33(7):1191-1197. doi: 10.1080/03007995.2017.1292230. Epub 2017 Mar 7. PMID: 28166427.
15. Tiequn B, Guanqun C, Shuo Z. Therapeutic effects of Lactobacillus in treating irritable bowel syndrome: a meta-analysis. Intern Med. 2015;54(3):243-9. doi: 10.2169/internalmedicine.54.2710. PMID: 25748731.
16. Whelan K. Probiotics and prebiotics in the management of irritable bowel syndrome: a review of recent clinical trials and systematic reviews. Curr Opin Clin Nutr Metab Care. 2011 Nov;14(6):581-7. doi: 10.1097/MCO.0b013e32834b8082. PMID: 21892075.
17. Ford AC, Quigley EM, Lacy BE, Lembo AJ, Saito YA, Schiller LR, Soffer EE, Spiegel BM, Moayyedi P. Efficacy of prebiotics, probiotics, and synbiotics in irritable bowel syndrome and chronic idiopathic constipation: systematic review and meta-analysis. Am J Gastroenterol. 2014 Oct;109(10):1547-61; quiz 1546, 1562. doi: 10.1038/ajg.2014.202. Epub 2014 Jul 29. PMID: 25070051.
18. Zhang C, Jiang J, Tian F, Zhao J, Zhang H, Zhai Q, Chen W. Meta-analysis of randomized controlled trials of the effects of probiotics on functional constipation in adults. Clin Nutr. 2020 Oct;39(10):2960-2969. doi: 10.1016/j.clnu.2020.01.005. Epub 2020 Jan 14. PMID: 32005532.
19. Sun YY, Li M, Li YY, Li LX, Zhai WZ, Wang P, Yang XX, Gu X, Song LJ, Li Z, Zuo XL, Li YQ. The effect of Clostridium butyricum on symptoms and fecal microbiota in diarrhea-dominant irritable bowel syndrome: a randomized, double-blind, placebo-controlled trial. Sci Rep. 2018 Feb 14;8(1):2964. doi: 10.1038/s41598-018-21241-z. PMID: 29445178; PMCID: PMC5813237.
20. Leventogiannis K, Gkolfakis P, Spithakis G, Tsatali A, Pistiki A, Sioulas A, Giamarellos-Bourboulis EJ, Triantafyllou K. Effect of a Preparation of Four Probiotics on Symptoms of Patients with Irritable Bowel Syndrome: Association with Intestinal Bacterial Overgrowth. Probiotics Antimicrob Proteins. 2019 Jun;11(2):627-634. doi: 10.1007/s12602-018-9401-3. Erratum in: Probiotics Antimicrob Proteins. 2019 Jun;11(2):635-637. doi: 10.1007/s12602-018-9412-0. PMID: 29508268; PMCID: PMC6541575.
21. Wen Y, Li J, Long Q, Yue CC, He B, Tang XG. The efficacy and safety of probiotics for patients with constipation-predominant irritable bowel syndrome: A systematic review and meta-analysis based on seventeen randomized controlled trials. Int J Surg. 2020 Jul;79:111-119. doi: 10.1016/j.ijsu.2020.04.063. Epub 2020 May 6. PMID: 32387213.
22. Pimentel M, Constantino T, Kong Y, Bajwa M, Rezaei A, Park S. A 14-day elemental diet is highly effective in normalizing the lactulose breath test. Dig Dis Sci. 2004 Jan;49(1):73-7. doi: 10.1023/b:ddas.0000011605.43979.e1. PMID: 14992438.
23. Homko CJ, Duffy F, Friedenberg FK, Boden G, Parkman HP. Effect of dietary fat and food consistency on gastroparesis symptoms in patients with gastroparesis. Neurogastroenterol Motil. 2015 Apr;27(4):501-8. doi: 10.1111/nmo.12519. Epub 2015 Jan 19. PMID: 25600163.
24. Limketkai BN, LeBrett W, Lin L, Shah ND. Nutritional approaches for gastroparesis. Lancet Gastroenterol Hepatol. 2020 Nov;5(11):1017-1026. doi: 10.1016/S2468-1253(20)30078-9. PMID: 33065041.
25. Andrews CN, Woo M, Buresi M, Curley M, Gupta M, Tack J, Wilsack L, Nasser Y. Prucalopride in diabetic and connective tissue disease-related gastroparesis: Randomized placebo-controlled crossover pilot trial. Neurogastroenterol Motil. 2021 Jan;33(1):e13958. doi: 10.1111/nmo.13958. Epub 2020 Aug 2. PMID: 32743954.