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Postprandial symptoms in disorders of gut-brain interaction and their potential as a treatment target
  1. Alexander C Ford1,
  2. Heidi M Staudacher2,
  3. Nicholas J Talley3
  1. 1 Leeds Gastroenterology Institute, St James's University Hospital, Leeds, UK
  2. 2 Deakin University—Geelong Waterfront Campus, Geelong, Victoria, Australia
  3. 3 Health, University of Newcastle, Callaghan, New South Wales, Australia
  1. Correspondence to Professor Alexander C Ford, Leeds Gastroenterology Institute, St James's University Hospital, Leeds, UK; alexford{at}nhs.net

Abstract

Postprandial, or meal-related, symptoms, such as abdominal pain, early satiation, fullness or bloating, are often reported by patients with disorders of gut-brain interaction, including functional dyspepsia (FD) or irritable bowel syndrome (IBS). We propose that postprandial symptoms arise via a distinct pathophysiological process. A physiological or psychological insult, for example, acute enteric infection, leads to loss of tolerance to a previously tolerated oral food antigen. This enables interaction of both the microbiota and the food antigen itself with the immune system, causing a localised immunological response, with activation of eosinophils and mast cells, and release of inflammatory mediators, including histamine and cytokines. These have more widespread systemic effects, including triggering nociceptive nerves and altering mood. Dietary interventions, including a diet low in fermentable oligosaccharides, disaccharides, monosaccharides and polyols, elimination of potential food antigens or gluten, IgG food sensitivity diets or salicylate restriction may benefit some patients with IBS or FD. This could be because the restriction of these foods or dietary components modulates this pathophysiological process. Similarly, drugs including proton pump inhibitors, histamine-receptor antagonists, mast cell stabilisers or even tricyclic or tetracyclic antidepressants, which have anti-histaminergic actions, all of which are potential treatments for FD and IBS, act on one or more of these mechanisms. It seems unlikely that food antigens driving intestinal immune activation are the entire explanation for postprandial symptoms in FD and IBS. In others, fermentation of intestinal carbohydrates, with gas release altering reflex responses, adverse reactions to food chemicals, central mechanisms or nocebo effects may dominate. However, if the concept that postprandial symptoms arise from food antigens driving an immune response in the gastrointestinal tract in a subset of patients is correct, it is paradigm-shifting, because if the choice of treatment were based on one or more of these therapeutic targets, patient outcomes may be improved.

  • FUNCTIONAL DYSPEPSIA
  • FUNCTIONAL BOWEL DISORDER
  • IRRITABLE BOWEL SYNDROME
  • FOOD ALLERGY

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Footnotes

  • X @hmstaudacher, @Prof_NickTalley

  • Contributors ACF is guarantor. He accepts full responsibility for the work and controlled the decision to publish. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. NJT, HS and ACF conceived and drafted the study. ACF, HS and NJT drafted the manuscript. All authors have approved the final draft of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.