5 Ways Sleep Apnea Can Cause Gastrointestinal Problems

Digestive and gastrointestinal problems are not commonly thought of when you mention obstructive sleep apnea. I used to think this way as well until I met Lorraine, a woman in her 30s who was thin and healthy looking on the outside. However, she hated waking up in the mornings due to her severe, throbbing headaches, and felt like she only slept for two hours, despite sleeping eight hours. She also had years of chronic diarrhea, bloating, and stomach cramping that came on just after eating.
 
She was found to have mild obstructive sleep apnea, but couldn’t tolerate CPAP and dental appliances. After a long discussion and after trying a number of conservative options, she decided to undergo surgery to address obstruction behind her soft palate and tongue. 
 
Three months after surgery, her headaches, fatigue and sleep problems improved significantly, and her sleep study didn’t show any more apneas. What caught my attention, however, was that she reported that all her gastrointestinal problems went away completely.
 
It’s well known that obstructive sleep apnea is strongly linked to high blood pressure, diabetes, heart attack, and stroke.  When I went to the literature, I found only a few studies looking at sleep apnea and gastrointestinal issues and sleep apnea. As expected, the most common condition that came up was acid reflux.
 
Before I begin describing these studies, it’s important to look at what happens when you’re under chronic stress. Having untreated obstructive sleep apnea or upper airway resistance syndrome can cause a stress response on your body. I had a major revelation when I read Robert Sapolsky’s book, Why Zebras Don’t Get Ulcers. The main concept that I got out of his book was that if you’re being chased by a tiger, that last thing you want to do is to reproduce or digest. 
 
Then there’s a story about a civil war soldier who suffered a major abdominal blast injury, leaving his intestines completely exposed. Doctors noted that when he was in a good mood, the bowels looked pink and vibrant. During painful procedures, the bowels looked dark and dusky. This story supports Zapolsky’s tiger example that during times of acute stress, blood flow and nervous system activation is diverted away from the bowels, in favor of your heart and core muscles, so you can fight or run. 
 
Similarly, people with obstructive sleep apnea will have chronic, low-grade degrees of physiologic stress, diverting blood flow and nutrient supply away from the gut. Now imagine if you ate a meal. The normal digestive processes of acid secretion, bile formation, peristalsis (rhythmic movement of the muscles) and absorption is going to be impaired. Imaging what can happen when you place food in your stomach. It can cause bloating, pain, indigestion, diarrhea or constipation. 
 
Here are 5 gastrointestinal conditions that have documented associations with sleep disturbances or obstructive sleep apnea.
 
1. Irritable Bowel Syndrome (IBS)
 
The example I gave in the beginning of this piece is a young woman with IBS. In a small study from Soroka and Ben-Gurion Universities in Israel, researchers found increased sleep fragmentation, 2x higher arousal index, and lower levels of slow wave (deep) sleep in subjects with IBS. Not too surprisingly, 3/6 of the subjects with IBS had OSA. The remainder probably had upper airway resistance syndrome (UARS).
 
2. Inflammatory bowel disease (Chron’s, Ulcerative colitis)
 
Researchers from Rush University compared sleep quality in patients with inflammatory bowel disease (IBD, Chron’s or ulcerative colitis), irritable bowel syndrome (IBS), and controls. The average AHI was 7-8 vs. < 1 in controls. Thirteen percent of all participants had obstructive sleep apnea. Of note, the arousal index was twice as high for people with IBD and IBS vs. controls. 
 
3. Celiac Disease
 
Although there are reports of sleep apnea improving after going on a gluten-free diet, a study from the University of Naples found that a gluten-free diet didn’t improve sleep quality scores in celiac patients.  In a blog I wrote a while back on celiac disease, I made the observation that every patient I know with celiac symptoms (whether celiac disease, or gluten sensitivity) has small jaws with very narrowed airways.
 
4. Colon cancer
 
It’s been shown that lack of sleep or  too much sleep ups your risk of colon cancer. In this landmark study from Spain, obstructive sleep apnea was linked to higher rates of cancer (all types). Of note, this increased risk was seen only in men less than 65 years of age. Lower levels of oxygen were found to correlate better with increased cancer risk than the AHI. The most common type of cancer was colon cancer. The other common cancers seen were prostate, lung and breast cancers. 
 
5. Acid reflux
 
One of the basic tenets of obstructive sleep apnea is its’ strong association with acid reflux. There have been tomes of studies describing how obstructive sleep apnea can aggravate reflux and vice versa. Studies have shown that treating OSA can help reflux symptoms and treating reflux can lower OSA severity scores. Vacuum-like negative pressures created in the chest wall from apneas is a simple explanation for this condition. What comes up is not only acid, but bile, digestive enzymes and bacteria. There are documented reports of pepsin (a digestive enzyme) in middle ear, sinus and lung washings. Imagine what these substances can do to your teeth, especially if you are a mouth breather with lower levels of saliva which has alkaline properties. 
 
 
Sleep physicians have observed that the most common symptom of jet lag is constipation. Your digestive system is strongly linked with your circadian and sleep patterns. Add to this repeated choking episodes from obstructive sleep apnea or upper airway resistance syndrome and it’s not surprising that we’re finding these associations. 
 
If you suffer from any of the the above conditions, how has treating sleep apnea (using CPAP, dental appliances or surgery) helped? Please enter your response in the area below.

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15 thoughts on “5 Ways Sleep Apnea Can Cause Gastrointestinal Problems

  1. You forgot Gastroparesis? Gastroenterologists never think to check for OSA for some reason. I asked my friend who is a ped GI about it and he said I wouldn’t understand, mumbling something about ENTs always falsely diagnosing stuff. But most cases of Gastroparesis are actually idiopathic and I wonder whether most of those are actually undiagnosed OSA. It was pretty miserable for me when I had it and CPAP did eventually cure the condition. Which was good because the drugs I was on were pretty nasty in comparison.

  2. I have had GERD for years, and IBS, too. Medication (venlafaxine) took care of the IBS, and pantoprazole the GERD. CPAP/BiPap has not made any difference in this problem so far as I can tell. I have not tried going off medication.

  3. Adam,

    Thanks for mentioning gastroparesis. This is something that’s more commonly associated with diabetes, but it can also be placed broadly under the IBS category. Good sleep helps your digestive system in general. Glad to hear that your gastroparesis got better on CPAP.

  4. are you familiar with the “Nightlase” protocol .Non-surgical laser therapy to reduce upper airway collapse, convert and stimulate new collagen formation to restore tone to lax tissues.

  5. Dr.Steven Park: Can you tell us what kind of surgery Lorraine has done? Is it especially suitable for someone who is thin and has gastrointestinal conditions ?

  6. Dr Park, is there a sleep specialist here in Western Australia that you could recommend? I am a 54 year old woman who is financially dependent on my life long partner, Mark. I am unemployable due to my inconsistent health and have paid out ridiculous amounts of money trying to resolve my health problems – otherwise I’d be on a plane to see you! I have been Dx with ADHD, IBS, hypertension, adrenal fatigue, migraine, premenstrual dysphoric disorder and narcolepsy. I believe I have sleep apnoea but my sleep study did not reveal this, although I was recoded to have quite a few apnoeas, but not enough to be considered ‘enough’. I was also awake for around half an hour but not aware of it and one very late, short REM episode. My symptoms are unpredictable – could that be due to inconsistency between each nights quality of sleep? Could the sleep study be a false reading as I didn’t sleep deeply enough in a strange environment? After discussing my symptoms the specialist who did not really seem interested in my plight, did diagnose me with narcolepsy without catoplexy. Help!

  7. CPAP has helped my laryngopharyngeal reflux during sleep, but it has given me no carry-over daytime benefits. I still always need a bottle of Tums on-hand for when my throat swells up after eating a meal. And I have to do exercise on an empty stomach, if I don’t want to re-taste all the food I had earlier in the day. I’m looking forward to my upcoming jaw surgery to improve my reflux problems.

  8. Ms. Hardwick,

    Sorry to hear about your health problems. Unfortunately, I don’t know anyone in Australia that’s familiar with upper airway resistance syndrome (UARS). Regardless, it’s difficult to recommend treatment options without formally examining you first. Since there’s no pill for UARS, many of the treatment options include gadgets, mechanical devices, or surgery.

    You’re best bet is to find a health care practitioner that is open to new ideas and is willing to try OSA treatment options, despite not formally having obstructive sleep apnea on polysomnography.

    Good luck…

    SP

  9. She had a uvulopalatopharyngoplasty with hyoid and tongue base suspension. It’s not important what type of surgery she underwent, but where in the throat her surgery addressed.

  10. Dr. Schiffman,

    Yes, I’ve read about it and seen some videos. I have no doubt that any technology that stiffens the soft palate can help with snoring, but in general, I don’t recommend options for OSA that don’t have formal prospective studies with good results. For snoring, it sound like it can work to various degrees like many of the other palate stiffening options out there. The question is how long it will last, and are you testing to make sure you don’t have sleep apnea. My guess is that it may help some patients with milder degrees of OSA, like the other options for snoring (Pillar, injection snoreplasty, CAUP, etc.).

  11. Hi I just wanted to follow up on my post from last month. It’s been a little over a week since I’ve had my jaw advancement surgery done, and so far it looks like my laryngopharyngeal reflux has been eliminated (all forms of reflux for that matter).

  12. I have suffered from extreme stress. Though, I responded well to the CPAP at first, the long term stress that I was exposed to has taken a toll. I was pulling the CPAP off in my sleep. I am gluten intolerant ,have IBS, constantly wake with a stuffed nose and have suffered extreme sleep deprivation for several months. I also feel as if I may have an ulcer. The sleep doctor nor the gastroenterologist have taken me seriously even though I tried to get them to understand that it had to be related. I have had to research and learn all about this own my own. That is how I discovered you Dr. Park. Though, I live in the Carolinas, I have made an appointment to come and see you, but I cannot get in until October. My sleep deprivation caused serious problems that the MD’s here are not equipped to handle. I also have a small airway and can feel my airway collapsing if I am about to go to sleep and even with my head back and resting while in the car or flying. I am desperate.

  13. Janine;
    Hi, I’ve been on cpap for almost 5 mos. and am very slowly and intermittently having improvement in my sleep. How long were you on cpap? Some people get good results after trying and trying over many months. And to get more sleep and get rid of the chronic insomnia and fragmented sleep, restless legs and other nerve problems I have (had), I’m willing to keep trying. Have you tried anything to relieve the congestion so you don’t remove the mask in your sleep. I’ve done that a few times as well but only when congested.

    Have you tried a full face mask so you must breathe through your mouth? The Amara View mask is the smallest and lightest full face mask. Also, about 8 mos after my insomnia started, (3 yrs ago) I was having this burning pain in my upper stomach, right below the left breast. Is that what you have? I finally had an endoscopy that revealed gastritis. I believe it was caused by stress from the chronic insomnia (and neurology symptoms like numbness and tingling) and not knowing what was causing it. Gastritis has similar symptoms to ulcers. I also think undiagnosed sleep apnea or UARS causes inflammation and the ongoing poor quality sleep can cause overgrowth of bad bacteria, causing inflammation. I’ve also had pain from urethritis and vaginitis which seem to be getting better lately. Doctors would tell me that I just had anxiety. Never sent me to a sleep clinic, most likely because I’m small and have a small neck. I also don’t have high blood pressure. My sleep apnea is extreme on my back and mild on my side. I had been shifting to my back off and on for years. This must have caused the unrefreshing, restless sleep I had off and on. You might want to try sleeping on your side at all times. Do not let yourself fall asleep in a recliner. When I do that, I jerk or snort awake and then I’m wide awake. Look up slumber bump belt, it’s sold on Amazon and it will make you stay on your side.

  14. I’ve had sleep apnea for about 20 years & have a cpap which wakes me up regularly. I’ve also been on Omeprazole for acid reflux for many years. I am now suffering with IBS symptoms. I am 61 years old, exercise for 1 hour most days, bicycling or swimming laps, and am normal weight. I ate lots of fruit & vegetables before this happened 3 months ago. Help!

  15. Dr park, we need more medical professionals like you in USA who thinks and treat root cause not just symptoms. I have severe sleep apnea and suffering from so many other things but sleep apnea is the root cause. I am on line to have MMA surgery with dr Majid Jamali in New York. I just hope it goes well and God gives me a cure. At age 36 I am fighting for my life. I read your post daily basis and get some hope.
    Thanks for being someone who is making difference in how we think about everything.