Why Your Stomach Is Always Upset: The Real Reasons and What Actually Helps
Why Your Stomach Is Always Upset: The Real Reasons and What Actually Helps
Persistent gut problems almost always have a cause. Finding it is a better plan than managing symptoms forever.
Digestive complaints are among the most common reasons people see a doctor, and among the most commonly dismissed. "It's probably just stress." "Try cutting out gluten." "Have you tried probiotics?" Sometimes these answers are right. More often, they're guesses dressed up as advice.
Let me walk through the most common real causes of persistent digestive discomfort, and what the evidence actually supports for each.
The Most Likely Culprits
Acid Reflux (GORD)
The lower oesophageal sphincter (the valve between your oesophagus and stomach) doesn't close properly. Stomach acid pushes up. You feel it as heartburn, a sour taste at the back of your throat, a burning in your chest, or chronic throat clearing.
Common triggers: lying down after eating, large meals, coffee, alcohol, spicy food, obesity, and smoking. Symptoms also worsen with certain medications (NSAIDs, aspirin, calcium channel blockers).
What actually helps: The evidence supports elevating the head of the bed by 15 to 20cm, not eating within 3 hours of sleeping, and weight loss in people who are overweight. PPIs (omeprazole, lansoprazole) are effective short-term but weren't designed for years of continuous use. If you've been on them for more than 8 weeks without a clear plan to step down, that's worth discussing with your doctor.
Irritable Bowel Syndrome (IBS)
IBS is a functional gut disorder. The gut structure is normal, but how it moves, how sensitive it is, and how it communicates with the brain is disrupted. This produces bloating, cramping, altered bowel habits (diarrhoea, constipation, or both), and pain that typically improves after a bowel movement.
The Rome IV criteria define IBS as recurrent abdominal pain at least 1 day per week for the last 3 months, associated with 2 or more of: changes related to defecation, changes in stool frequency, or changes in stool form.
The low-FODMAP diet has the strongest evidence for IBS: 3 randomised controlled trials show symptom improvement in 50 to 80% of patients. It's not a permanent elimination diet; it's a structured 6 to 8 week test phase followed by reintroduction of specific foods. The approach requires a dietitian, not a YouTube video.
Small Intestinal Bacterial Overgrowth (SIBO)
Your large intestine is supposed to host most of your gut bacteria. In SIBO, bacteria colonise the small intestine, where they ferment carbohydrates before your body can absorb them. This produces hydrogen and methane gas, causing significant bloating, distension, and altered bowel habits.
SIBO is diagnosed with a breath test (hydrogen/methane breath test). It's more common than people realise, particularly after a GI infection, after abdominal surgery, or in people with IBS, hypothyroidism, or diabetes.
Coeliac Disease
Coeliac disease is not a food sensitivity. It's an autoimmune condition where gluten triggers an immune response that damages the villi (the tiny projections that absorb nutrients) in the small intestine. Symptoms range from classic (diarrhoea, weight loss, bloating after eating wheat or barley) to atypical (fatigue, anaemia, bone pain, mouth ulcers, infertility).
Diagnosis requires: tTG-IgA blood test, then gastroscopy with small bowel biopsy while still eating gluten. Do not go gluten-free before testing; it normalises the blood test and makes biopsy results unreliable.
Helicobacter pylori Infection
Around 44% of the global population carries H. pylori. In many, it causes no symptoms. In others, it causes chronic gastritis, peptic ulcers, and significantly increases the risk of stomach cancer. Symptoms when present: burning upper abdominal pain (often worse at night or between meals), nausea, bloating, and burping.
Diagnosed with a urea breath test, stool antigen test, or biopsy. Treated with triple therapy: 2 antibiotics plus a PPI for 7 to 14 days. Eradication rates are 80 to 90% with proper treatment.
Lactose Intolerance
Lactase breaks down lactose (milk sugar). Without enough of it, undigested lactose reaches the colon, where bacteria ferment it, producing gas and causing bloating, cramping, and diarrhoea within 30 minutes to 2 hours of dairy consumption. It's a spectrum: some people can tolerate small amounts; others can't manage any.
What the Evidence Says About Common Remedies
Peppermint oil (enteric-coated): A 2014 meta-analysis in the Journal of Clinical Gastroenterology found enteric-coated peppermint oil significantly reduced IBS symptoms compared to placebo. The enteric coating prevents it dissolving in the stomach (which would cause heartburn); it dissolves in the intestine, where it relaxes smooth muscle.
Soluble fibre (psyllium/ispaghula): Strong evidence for IBS-C and general constipation. The NNT (number needed to treat) is around 6, meaning 1 in 6 patients sees significant improvement. Insoluble fibre (wheat bran) worsens symptoms in some IBS patients.
Probiotics: Effect is strain-specific and condition-specific. Lactobacillus rhamnosus GG has the best evidence for post-antibiotic diarrhoea. Bifidobacterium infantis 35624 has shown benefit in IBS in 2 trials. Generic "probiotic yoghurt" is not the same thing.
The Gut-Brain Axis: Why Stress Is Real, Not an Excuse
The gut has its own nervous system: the enteric nervous system, sometimes called the "second brain." It contains roughly 500 million neurons. It communicates constantly with the brain via the vagus nerve.
This is why anxiety causes diarrhoea and stress causes flares of IBS. It's not "all in your head." It's bidirectional neuroscience. Chronic stress changes gut motility, intestinal permeability, and the microbiome composition.
Gut-directed hypnotherapy (a weird-sounding thing with surprisingly strong evidence) has an RCT-proven response rate of around 70% in IBS, comparable to the low-FODMAP diet. Cognitive behavioural therapy adapted for IBS also has several positive trials.
Unintentional weight loss. Blood in stool (red or black tarry stools). Persistent vomiting. Dysphagia (difficulty swallowing). Nocturnal symptoms that wake you from sleep. Onset of significant GI symptoms after age 50. Family history of bowel cancer or inflammatory bowel disease. These warrant investigation, not watchful waiting.
The Bottom Line
Persistent digestive symptoms deserve a real diagnosis, not indefinite symptom management. Conditions like coeliac disease, H. pylori, and SIBO are treatable. IBS has several evidence-based approaches that go well beyond "avoid spicy food."
Start by tracking: when symptoms occur, what you ate, stress levels, bowel habits. Then take that information to a doctor who will actually investigate, not just prescribe another PPI.
A good gut history takes 10 minutes and rules out a lot. An ignored gut history becomes a colonoscopy at 50 that finds something that's been growing for years.
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