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Food and Hypersensitivity in Functional Dyspepsia N W Read

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Food and Hypersensitivity in Functional Dyspepsia N W Read i50 VISCERAL PERCEPTION Gut: first published as 10.1136/gut.51.suppl_1.i50 on 1 July 2002. Downloaded from Food and hypersensitivity in functional dyspepsia N W Read ............................................................................................................................. Gut 2002;51(Suppl I):i50–i53 It has long been known that stress affects both the many, digestion of a meal is a good experience stomach and colon, as shown by the very high that is associated with feelings of satisfaction, relaxation, comfort, and well being. It is truly said prevalence of gastrointestinal symptoms among patients that a family that eats together stays together. Or with psychiatric illness. The source may be limbic or the way to a man’s (or a woman’s) heart is peripheral, involving encoded memories or through his (her) stomach. Eating together induces feelings of peace and friendship, which physiological changes. It is important to realise that encourage communication and collaboration. But physical symptoms such as those of functional dyspepsia how different it is for those unfortunate people do not only mean that the patient has a stomach who suffer with functional dyspepsia. They are so tortured with indigestion, bloating, pain, or disorder which needs to be identified and treated with heartburn that every meal is a torment that specific pharmacological remedies, they often represent, causes anxiety and frustration, and results in in metaphorical and symbolic form, a state of social exclusion and isolation. It is as if the stom- ach is revolting against the very idea of food and disharmony brought about a specific psychosocial just wants to get rid of it or at least take in as little situation. It is only when that situation is understood and as possible. acknowledged that the patient can begin to get better. Physiological studies of gastroduodenal motil- ity reflect this state of confusion. Instead of the .......................................................................... food emptying from the stomach in a calm regu- lated manner driven by steady peristaltic waves SUMMARY that sweep down from the incisura through the It has long been known that stress affects both pylorus to be continued by clusters of contrac- the stomach and colon. This has been shown by tions in the duodenum, gastric emptying is brain imaging techniques, and by the very high frequently delayed. The delay is associated with prevalence of gastrointestinal symptoms among lack of fundal compliance, disturbed duodenal http://gut.bmj.com/ patients with psychiatric illness. The source may contractility with more retroperistalsis and duo- be limbic or peripheral, involving encoded memo- denogastric reflux, an abnormal distribution of ries or physiological changes. Unpublished data food, and an abnormal antral dilatation. All of from more than 700 in depth psychoanalytical these are physiological features of nausea. Thus it interviews with patients with various functional appears that although the stomach is in the proc- gastrointestinal disorders suggest that there is a ess of trying to digest food, it has adopted the subgroup of patients with irritable bowel syn- posture for vomiting. It is “totally confused” not drome (IBS) and functional dyspepsia that have knowing whether it wants to digest the meal or on September 23, 2021 by guest. Protected copyright. difficulty in expressing emotion. In these indi- throw it up. viduals, the outworking of painful memories is I have a group of patients who live with this realised by the recruitment of heightened visceral sort of gastric revolt every day of their lives. sensation and symptoms. These patients typically Things are so difficult that it takes an age to get present with complex psychological and gastro- enough food down to keep them alive. Take Sally intestinal symptomatology that impairs their for example. She cannot eat with the rest of her quality of life. They constitute a subgroup that is family. If she tries, she has difficulty in swallow- clearly very different from those with functional ing, her mouth goes dry, and the food seems to get disorders who complain of a single symptom stuck half way down. If it gets as far as the stom- without associated emotional problems. These ach, she gets such severe abdominal cramping observations highlight the need to recognise that and nausea that it can often come straight back physical symptoms such as those of dyspepsia do again. The only way Sally can take enough food in not just mean that a patient has a stomach disor- is to eat in the early hours of the morning when der that needs to be diagnosed and treated with everybody else is asleep. Even then she has to eat specific pharmacological remedies. Instead, we very slowly, averting her gaze from what she is should embrace the idea that presenting symp- eating, and reading a book to distract herself. ....................... toms often represent, in metaphorical and sym- Sally has a seriously ambivalent oesophagus and bolic form, a state of disharmony brought about stomach. Thus clearly the way we understand Correspondence to: by a specific psychosocial situation, and its is only functional gastrointestinal disorders does not Professor N W Read, 1 Centre for Human when that situation is understood and acknowl- have to be limited by the Rome II declarations. Nutrition, Coleridge edged that the patient can begin to get better. House, Northern General Hospital, Sheffield INTRODUCTION: A REVOLT IN THE GUT ................................................. S5 7AU, UK; [email protected] It is often useful to envisage functional dyspepsia Abbreviations: CCK, cholecystokinin; IBS, irritable bowel ....................... as the confused and tormented stomach. For syndrome. www.gutjnl.com Food and hypersensitivity in functional dyspepsia i51 PHYSIOLOGICAL STUDIES OF NUTRIENT SPECIFIC conducted over 700 in depth psychoanalytical interviews with GASTRIC HYPERSENSITIVITY patients with various functional gastrointestinal disorders. Several studies have shown that the stomach is more sensitive This experience, by its very nature highly subjective, strongly Gut: first published as 10.1136/gut.51.suppl_1.i50 on 1 July 2002. Downloaded from to distension in those with functional dyspepsia than in suggests that functional dyspepsia is a state of emotional healthy subjects,2 suggesting that, in common with the ambivalence represented by digestive conflict. So what does overlapping syndrome of irritable bowel syndrome (IBS), this mean in physiological terms? functional dyspepsia may be a disturbance of visceral In healthy subjects the presence of lipids in the duodenum sensation. But this is not the whole story. Patients with symp- induces comfortable sensations of satisfaction or fullness, toms of functional dyspepsia often report that meals, which similar to those experienced after a meal. It also causes are rich in fat, are particularly likely to cause them discomfort. feelings of well being, relaxation, friendliness, tranquillity, and This phenomenon has been investigated in our laboratory.3 drowsiness.6 In animals, the same experiment induces a These studies specifically tested the hypothesis that the pres- grooming sequence followed by sleep. Dimasio has recently ence of lipid in the small intestine makes the dyspeptic stom- suggested that what we understand by emotion actually ach more sensitive to distension. comes from our feelings, as conveyed to the brain via visceral Ten patients with functional dyspepsia and 10 healthy con- afferent nerves.7 These experiments would support that idea. trol subjects were studied on two occasions separated by at Supposing however that the act of eating a meal is least seven days. On the morning of the study, after an associated with anxiety or tension. This would interrupt the overnight fast, a single lumen polyvinyl tube equipped with a peaceful reverie of digestion by stimulating the sympathetic side opening near the weighted tip was introduced through nervous system which in turn would inhibit peristalsis, reduce the nose and positioned in the duodenum under fluoroscopy. the output of digestive secretions, and increase visceral sensi- When this was in place, each subject swallowed a flexible tivity. Previous studies have shown that excitation of the sym- double lumen polyvinyl tube that had an ultrathin polythene pathetic nervous system by experimental stressors,8 peripheral bag with a maximum capacity of 1.2 litres wrapped around its venous pooling,9 and focused attention10 increase visceral sen- distal end. This was used to distend the stomach and record sitivity while relaxation and distraction reduces it. It is also gastric pressure. known to us all that if we do not give ourselves enough time Each experiment lasted 2.5 hours and was performed with to eat a meal, or we try to eat while we are emotionally upset, subjects lying in a 30° semirecumbent position. Normal saline we are likely to get indigestion. Emotional tension while we was infused into the duodenum at a rate of 1 ml/min for just are eating induces a physiological state of digestive conflict; over an hour. This was followed either by an infusion of the vagus is trying to facilitate peaceful digestion while the Intralipid (Kabivitrum) at the same rate (delivering 1 kCal/min) or a second control infusion of saline. Subjects sympathetic nervous system is trying to alert the organism to were unaware of the nature of the infusion. After each action. The result is that the person feels anxious and tense infusion had
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