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Gastrointestinal (GI) symptoms can arise from a number of physiological and pathological processes including inflammation, infection and malignancy.1 Such symptoms are a common cause for referral to secondary care. They impair quality of life, even in the absence of organic pathology.2
GI symptoms are common in endurance sports, particularly running. Prevalence of symptoms varies depending on the event, assessment tool used and what is classified as a ‘symptom’ in each study, but between 30% and 90% of individuals have reported GI symptoms.3 However, there has been less research in examining the prevalence of such symptoms in other sports, particularly at elite level. This is surprising given that many of the factors associated with GI damage and symptoms are commonly seen in sport, such as use of non-steroidal anti-inflammatories, GI ischaemia during high-intensity exercise, a wide variety of dietary habits, use of buffering supplements such as sodium bicarbonate and mechanical effects such as bouncing of organs.4 Furthermore, GI illnesses are often one of the most commonly diagnosed during major international sporting events.5
Prevalence of GI symptoms in elite sport
We surveyed 249 elite athletes from a range of sports (football, rugby league, rugby union, taekwondo, horse racing, ultramarathon, cycling and cricket) using the Gastrointestinal Symptom Rating Scale (GSRS).6 The GSRS contains 14 items, each rated on a 7-point Likert scale from no discomfort to very severe discomfort relating to abdominal pain, hunger pains, nausea, heartburn, acid regurgitation, diarrhoea, loose stools, rumbling, abdominal distension, belching, increased flatulence, constipation, hard stools and feeling of incomplete evacuation. Participants were asked to score each symptom in relation to the previous 7 days. Results are shown in table 1.
Gastrointestinal symptom rating scale scores of elite athletes (n=249)
Gastrointestinal symptoms of any severity were common with 86% of respondents reporting at least one symptom, and 15% reported at least one symptom rated as ‘moderately severe’ or worse. The frequency symptoms varied with abdominal site. For symptoms of any severity, upper abdominal discomfort was experienced by 24% of respondents. Abdominal bloating and flatulence were reported in 48% and 44%, respectively. Twenty-one per cent reported urgency of faeces and 27% reported a sensation of incomplete emptying of bowels.
There were some age and sex differences in prevalence. Women were more likely to report ‘moderate’ level symptoms or worse for nausea, hunger pains, bloating and a feeling of incomplete evacuation. A symptom severity of ‘moderate’ or worse for bloating and a feeling of incomplete evacuation were also higher in those aged 25 and over compared with those below the age of 25.
Need for further research and athlete education
This high prevalence of GI symptoms in an elite athletic population suggests that certain individuals or groups are affected more greatly than others. The impact of high-intensity sport on the gut in terms of blood flow, motility, microbiome and permeability along with the impact of the athletic diet (in particular the role of supplements and sports drinks) warrant further attention.
Given the intimacy and potential embarrassment that symptoms may cause, athletes may choose not to raise any potential issues within the sporting structure. This is particularly pertinent given that at least one respondent from our data experienced ‘severe’ or ‘very severe’ discomfort in each symptom category. Therefore, formal annual screening and, where appropriate, specialist review by a gastroenterologist with an understanding of the athletic gut may be necessary. Equally, sports science and sports medicine practitioners should be able to recognise and distinguish between minor exercise or diet-related symptoms and those persistent or indolent symptoms, which are beyond their scope of practice and require further clinical follow-up to exclude sinister pathology.
Footnotes
Contributors All authors contributed equally to the manuscript.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.