Dear Doctor,
I am a competitive cyclist who has been experiencing excruciating abdominalpains after my training sessions. The episodes usually occur approximately15-30 minutes after I am finished. The symptoms are severe bloating andunbearable pain that sometimes doubles me over. Usually if I take an anti-gaspill the discomfort is minimal and shorter in duration. What do you thinkthe problem could be and what can I do about? -- HG

Dear HG:
Exercise-related abdominal pains like you're describing can have severalcauses. Your question is a good one because studies have shown than 30to 40 percent of athletes, both elite and fitness level, experience someform of gastrointestinal (GI) difficulties.

As an emergency physician, I'm trained to always first consider theworst possible explanation for a patient's situation and then prove whetheror not that is the correct dignosis. While this approach works well ingeneral, it is a bit extreme in my sports medicine practice and goes againstcertain natural tendencies of thought. As a result I like to teach buddingphysicians to simply allow themselves to think of the most likely explanationfor a patient's complaints, then think of two or three possible alternatives,and then consider the worst possible scenario. This approach workswell in your case.

By far the most likely cause of your complaints is something know asgastroesophageal reflux disease (GERD, also known as ARD for acid refluxdisease). This is "heartburn." It's the condition in which stomach acidmakes its way up into the esophagus causing pain in the pit of the stomachand in the chest. It's often described as "burning" in character, but canalso be like a spasm as the esophagus is sent into spasm by the irritatingacid.The following are some of the situations that can bring on exercise - relatedGERD:

- A non - exercise tendency for the problem. If you get GERD in your daily life, you'll almost certainly have trouble with it when training.
- Certain dietary factors can be problematic. Eating too soon before trainingcan be bad; at least a two hour gap is best. Coffee, orange juice, proteinsand fried foods can be troublesome.
- Non-steroidal anti-inflammatory drug (NSAID) use. Aspirin, ibuprofen, and naproxen are the NSAIDS available over-the-counter. Athletes of course use these for tendonitis, etc.
- Sports drinks can be a problem. Use water or mix your powdered sports drink more dilute than recommended. Also cool is better that hot.
- Dehydration.
- Duration of efforts. Longer effort equals higher likelihood of GERD.
- Age. Older in fact is better in this case, though this may relate to the preceding point!
- Tobacco use. I find that a surprising number of fit athletic people indulge in the daily or occasional evening-out cigarette or two. Elimination of this naughty habit may be the single most helpful anti-GERD action you can take.

The solution to many of these are obvious. Some have no solution. I encourage you to experiment with some of these that may be at play in your specific case. I often find that making only one change will result in relief of symptoms. All your system needs is a slight relief of one ofthe stressors for it to drop below the symptomatic threshold point. Specificantacid therapy is important too. I generally recommend an antacid/anti-gascombination (a calcium-based antacid plus simethicone) 30 minutes afterthe pre-training meal and again just before the workout. Of course over-the-counter antacid pills (cimtidine and ranitidine) are available, but I really prefer to avoid possible side-effects they may cause.Okay, now on to a couple of more serious potential causes of your symptoms.First it is important to consider the possibility of a cardiac cause for your pain. While not typical, your symptoms could represent strain on your heart that could lead to a heart attack. You don't mention your age, but this is the point where I strongly recommend to people "of a certain age" to have a proper medical evaluation before getting mixed up in all this exercise business. Probably those over 40, people with weight issues, elevated cholesterol, high blood pressure or a family history of heart disease should get checked out by a physician before undertaking a training program.

Finally a serious and very real possibility is that you are experiencingexercise-related reversible mesenteric ischemia. Let me explain. All theorgans of your body are happiest when they are getting the amount of bloodflow they need in order to perform their assigned tasks. When they don'tget that amount of flow, certain things happen that we have names for likemyocardial infarction ("heart attack") and cerebrovascular accident ("stroke").

In the case of the intestines, the name is mesenteric ischemia. Thisis an uncommon problem, which explains why most people don't know anythingabout it and why there is no layman's term for it. It is caused by thefact that the heart has a fixed capacity for pumping blood. During exercisethe working muscles hog the blood flow and the intestines get short-changedby as much as 80 percent of their usual blood supply.

Symptoms include pain, bloating, diarrhea and even bloody stools.

Risk factors for developing mesenteric ischemia are:

-Dehydration.
-Birth control pill (BCP) use.
-A genetic tendency for a hyperactive blood clotting system.
-Elevated hematocrit caused either by training at altitude, dehydration,or erythropoietin (EPO) use.
-Cholesterol blockage of the arteries supplying blood to the intestines.
-A structural abnormality of the arteries supplying blood to the intestines.

As before, some of these can be controlled and some cannot. You can focus on proper hydration and stop using BCPs, but you'll need professional help with the others.I suggest that you experiment with the GERD avoidance and treatment techniques. Also hydrate well and seriously consider stopping the use of BCPs if this applies to you. During this phase, if you experience rectal bleeding or some other serious worsening of your condition, seek care at your local Emergency Department. If however your symptoms continue as you describe despite these preventive and therapeutic efforts, you really should see a good gastroenterologist about this.Take this information with you, as I'm certain this is not a problem that your average gastroenterologist encounters frequently.Best wishes,
Prentice

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Dr. Prentice Steffen, board certified in both Emergency Medicine and Sports Medicine, is currently serving as team doctor for the Prime Alliance Cycling team. He has served as team doctor for several teams including Mercury, Spago and U.S. Postal. Steffen has also served as medical director and event physician for major races including the Tour Du Pont, New York City Marathon and the Tour de Trump. Steffen also serves as the Sports Medicine section editor for the Journal of Emergency Medicine. Please send your sports-related medical questions to "Ask the Doctor" in care of WebLetters@7Dogs.com. We will forward a selection of questions to one of three physicians currently working with this site.Important Notice:
The information provided in the ASK THE DOCTOR column does not constitute formal medical advice. The information provided on this public web site is provided solely for general interest of the visitors to the site. The information contained in this column applies to general medical practice and may not reflect current medical developments or be interpreted as medical advice. Understand that reading the information contained in this column does not mean that you have established a doctor-patient relationship with Dr. Prentice Steffen. Readers of this column should not act upon any information contained in the web site without first seeking medical advice from their personal physician.