What should I do about my chronic gastrointestinal issues?

Approach to Chronic Gastrointestinal Issues

Yes, I can help you understand and address your chronic GI issues—the key is systematic evaluation to identify specific treatable causes rather than accepting symptoms as "just the way things are." 1

Initial Assessment Framework

Your 3.5-year history of GI symptoms requires a structured diagnostic approach because:

• Multiple underlying causes typically coexist in patients with chronic GI symptoms, and identifying each specific physiological deficit is essential for effective treatment 1
• Symptoms alone cannot reliably identify the underlying cause—different physiological disorders produce similar symptoms, so comprehensive testing is necessary rather than empirical treatment 1
• The factors that initiated your problems may differ from those perpetuating them, so focusing solely on what started your symptoms can interfere with finding effective solutions 1

Critical Diagnostic Considerations

Rule Out Organic Disease First

Before attributing symptoms to functional disorders, you need evaluation for:

• Inflammatory bowel disease (check CRP, albumin, platelets, fecal calprotectin) 1
• Structural abnormalities including adhesions from any prior surgeries, which can cause intermittent obstruction with colicky pain, distension, and alternating constipation/diarrhea 1, 2
• Malignancy, particularly if you have unexplained weight loss, rectal bleeding, or are over 50 2
• Celiac disease and other malabsorptive conditions 1

Common Treatable Physiological Causes

The following conditions frequently coexist and cause chronic GI symptoms 1:

• Bile acid diarrhea (BAD): Causes urgency, frequent bowel movements, and often wakes patients from sleep; diagnosed by SeHCAT scan or empirical trial of bile acid sequestrants 1
• Small intestinal bacterial overgrowth (SIBO): Causes bloating, diarrhea, and malabsorption; should be diagnosed with breath testing rather than empirical antibiotics to aid antibiotic stewardship 1
• Pancreatic exocrine insufficiency (PEI): Causes steatorrhea, weight loss, and malabsorption; diagnosed by fecal elastase testing 1
• Carbohydrate intolerance: Particularly lactose and fructose malabsorption 1

Medication-Related Causes

Review all medications carefully 1:

• Opioid use can cause narcotic bowel syndrome—paradoxically worsening abdominal pain despite continued or escalating doses, along with severe constipation and dysmotility 1
• Anticholinergic medications impair motility 1
• Proton pump inhibitors used long-term (>3 years) can cause vitamin B12 deficiency, hypomagnesemia, and increased risk of SIBO 3, 1

Red Flags Requiring Urgent Evaluation

Seek immediate medical attention if you develop 2:

• Fever, rapid heart rate, confusion (suggesting bowel ischemia)
• Severe unrelenting pain unresponsive to analgesics
• Bloody stools with hemodynamic instability
• Progressive inability to tolerate oral intake with dehydration
• Significant unintentional weight loss (>10% in 3 months) 1

Recommended Diagnostic Pathway

Use validated symptom questionnaires (such as the Gastrointestinal Symptom Rating Scale) to comprehensively document all symptoms, as specialists often cannot predict which symptoms affect you most severely 1

Request comprehensive testing rather than accepting a functional diagnosis prematurely 1:

1. Complete blood count, comprehensive metabolic panel, inflammatory markers
2. Fecal calprotectin to exclude inflammatory bowel disease
3. Celiac serology
4. Breath testing for SIBO (glucose or lactulose)
5. SeHCAT scan or empirical bile acid sequestrant trial for suspected BAD
6. Fecal elastase for pancreatic function
7. CT enterography if structural disease suspected

Symptoms should not be attributed to irritable bowel syndrome until comprehensive investigation and trials of targeted treatment have excluded organic causes 1

Treatment Principles

Treatment must target identified physiological deficits, not just symptoms 1:

• Bile acid sequestrants (colesevelam preferred over cholestyramine for better tolerance) for BAD, starting at low doses with meals 1
• Antibiotics for confirmed SIBO (rifaximin is commonly used)
• Pancreatic enzyme replacement for PEI
• Dietary modifications based on identified intolerances

Avoid opioids entirely for chronic GI pain—they are ineffective for disorders of gut-brain interaction and risk causing narcotic bowel syndrome 1

If symptoms persist despite negative testing, consider referral to a gastroenterologist with specific interest in chronic GI symptoms, as specialized systematic approaches have proven beneficial in randomized trials 1

Common Pitfalls to Avoid

• Accepting a functional diagnosis too quickly without excluding treatable organic causes 1
• Assuming one diagnosis explains all symptoms when multiple conditions typically coexist 1
• Continuing ineffective treatments rather than pursuing comprehensive diagnostic evaluation 1
• Psychological inflexibility—overfocusing on finding "the cause" rather than addressing perpetuating factors and accepting that pain management may require behavioral approaches alongside medical treatment 1