Here’s What Alcohol Does to the Gut

Tina Aswani-Omprakash vividly remembers the day that led her to give up drinking forever. Her inflammatory bowel syndrome (IBS) had been in remission for two months, and she felt like her life had gone back to normal. But that didn’t last long. At a work event, after just a couple drinks, she began to feel queasy and then started vomiting so violently that a friend took her to the emergency room. When the 23-year-old New Yorker asked her doctor about the experience, he suggested she cut back on drinking if it was making her symptoms worse. Wanting to protect her health, she decided to quit completely. But for a 20-something working in a high-pressure job that required a lot of socializing with clients, it was hard. “Above and beyond being diagnosed with a life-long illness at 22, I couldn’t do one of the things that allowed me to fit in with my peers, colleagues, and clients,” says Aswani-Omprakash, who is now 40. Friends, dates, and co-workers would sometimes look at her like she had “nine heads,” she says, when she wouldn’t order a drink. “Initially, I didn’t cope well,” says Aswani-Omprakash. “But then I learned to order a non-alcoholic beverage—cranberry juice, a mocktail, or water, even—with a piece of lemon or lime on the side. That way, no one would know what I was drinking.” There’s no single answer to whether people with IBS or inflammatory bowel disease (IBD) can consume alcohol, experts say. As with certain foods, it requires experimentation to determine personal tolerance. But the question of whether a person should continue drinking isn’t simply a matter of tolerance. That’s because alcohol can affect the efficacy of some IBD medications and mess with test results. It’s best for patients who want to continue to drink to talk things over with their doctors, experts say.

What does alcohol do to the gut?

Even in people with healthy digestive systems, alcohol can wreak havoc, says Dr. Alexandra Gutierrez, a professor of medicine and the medical director of the IBD Center at the Columbia University Vagelos College of Physicians and Surgeons. While light consumption—a maximum of one drink a day for women and two for men—is unlikely to cause serious problems, heavier drinking can mess with the microbiome, leading to increases in the bacteria that cause inflammation and decreases in the bacteria that help us digest food, Gutierrez says. Even among those who don’t drink heavily, some will experience diarrhea and cramping. Increased inflammation associated with heavier drinking can also interfere with nutrient absorption. Worse, it can damage the intestinal lining and possibly cause “leaky gut.” That condition can lead to microbes, food, and toxins seeping out of the intestines, potentially causing problems elsewhere in the body. Even among those who stick to the alcohol guidelines, some will have digestive problems, such as changes in bowel habits and worsening acid reflux, says Dr. Reezwana Chowdhury, an assistant professor of medicine and an IBD specialist at the Johns Hopkins University School of Medicine.

What about people with IBD?

While the occasional drink doesn’t always cause harm, “there’s a proportion [of people with IBD] who will certainly feel worse when they drink because of disease flaring,” says Dr. Jessica Philpott, a gastroenterologist at the Cleveland Clinic. “A lot of times a patient will say, ‘I went out for a beer with some friends and felt bad the next day.’” When patients ask if they can drink in moderation, “I tell them it’s OK if they don’t have liver disease and it’s no more than two drinks in 24 hours for men and no more than one drink in 24 hours for women,” Chowdhury says. “When I go over their history, many will say, ‘When I drink I don’t feel good,’” she adds. “It’s not uncommon for a patient to say, ‘Before I was able to have three or four drinks on the weekend, and now I don’t feel good after just one beer.’” Some patients pay attention to what their bodies are telling them, but “some just continue to fight the feeling,” Chowdhury says. “I worry about the alcohol causing damage. My overall take home is that drinking is not recommended.” Alcohol can also impact the body’s ability to make the most of the food people consume. That’s because it pushes everything through the gut quickly, so there’s less time for nutrients to be absorbed—which in turn magnifies what IBD patients are already experiencing, says Dr. Nirupama Bonthala, an assistant professor of medicine and director of Women’s Health in Inflammatory Bowel Disease at the University of California, Los Angeles. Perhaps even more concerning is the impact that alcohol can have on certain IBD medications. “There are a couple medications that alcohol can make less effective,” Bonthala says. “And it can cause lots of test abnormalities, especially with liver function tests. It can be hard to tell whether what we’re seeing on the tests is a medication issue, or the alcohol, or liver issues caused by the IBD.” Depending on the timing of a patient’s drinking, some drugs may take longer to be metabolized, resulting in higher than optimal levels of the medication in the person’s system, Gutierrez says. Some doctors question their IBD patients about alcohol consumption and counsel them on the problems drinking can cause. Unfortunately, that’s not true of all of them. Aswani-Omprakash says she’s never had a doctor talk to her about alcohol’s potential impact on IBD. Some doctors, however, feel that it’s very important to have the discussion. “I ask every patient about alcohol,” says Dr. Baldeep Pabla, an assistant professor at the Vanderbilt University Medical Center. That’s because along with the potential impact on IBD symptoms, in heavier drinkers there can be damage to the liver and other organs, Pabla explains. “Alcohol is a heterogeneous and complex substance,” he adds. “So it affects people differently. And it’s one of the major causes of liver disease.” A large percentage of patients, some 20% to 30%, take those dangers to heart, self-restricting because they feel that alcohol makes their symptoms worse, Pabla notes.

Does everyone have to quit drinking?

It’s possible for at least some people with gut issues to drink in moderation. Laura Goldenkranz was diagnosed with IBD when she was 36, and for years after that she completely cut out alcohol. “I was having a rough time with severe flares,” she says. “And with the combination of not feeling well along with all the medications I was taking, I just abstained completely.” But a lot of things changed when Goldenkranz was prescribed a new medication—and that included her relationship with alcohol. Rinvoq put the 44-year-old New Yorker into remission, and now, she feels comfortable having an occasional drink in the evening. “I know that for some people, alcohol can really exacerbate their symptoms, but fortunately I’m now well enough that I haven’t noticed any impact.” When it comes to drinking, Goldenkranz is happy that she didn’t develop symptoms when she was in her 20s. “I think it makes a really big difference when you’re younger,” she says. “If I had been dealing with this when I was in college it would have been an issue. I was drinking more then. By the time I was diagnosed in my mid-30s, it didn’t matter because I wasn’t drinking very much.” There’s no question that younger people can feel stigmatized when they’re the only ones who can’t drink at social gatherings, Pabla says. The burgeoning market in non-alcoholic beverages may help with that, Pabla points out.

Are there certain types of drinks that are better than others?

There’s some research that suggests red wine might be the best choice for people who want to drink occasionally. In fact, Pabla says, some small studies have found that 1 to 3 grams of red wine per week might improve inflammation in the gut. In contrast, another study found that people who drank beer “had significantly worse endoscopic disease,” he says. It makes sense that red wine would be the best choice since it’s rich in phenols, which are known to have anti-inflammatory properties, Gutierrez says.

Are there signs that suggest it’s time to cut back or completely quit drinking?

Any time there’s a worsening of symptoms, it makes sense to consider the possibility that alcohol might be the cause. To determine whether drinking is at the root of digestive symptoms, “you can perform an experiment,” Pabla says. “Stop drinking, and if alcohol is the cause, you should see improvement within weeks.” Routine testing may also reveal problems. “If there are actual lab abnormalities, it’s a sign that you need to take a break,” Bonthala says. Alcohol is not essential to your life. Good gut health is.