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A response, and rebuttal, to Roland Valori's ‘top tips for managing patients with medically unexplained symptoms’
  1. Roland Valori,
  2. Hugh Shepherd
  1. High Shepherd, Sarum Road Hospital, Winchester, Hampshire; Roland Valori, Dept of Gastroenterology, Gloucestershire Royal Hospital, Gloucestershire
  1. Correspondence to Dr Anton V Emmanuel, Physiology Unit, University College Hospital, 235 Euston Road, London, UK; a.emmanuel{at}

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While this is a new departure for Frontline Gastroenterology, the editorial team felt that there were pressing arguments in favour of publishing the response to a published article from a highly experienced gastroenterologist. Coupled with the author's rebuttal, the exchange of views illustrates how important it is to learn from each other, especially about things that are not readily available in textbooks or just not taught in hospitals.


I applaud the concept of this type of article, which, in my experience, has been pioneered by our neurological colleagues in helping those less experienced in this discipline to tease out organic disease. I accept they are difficult articles to write, as every experienced clinician has their own way of doing things.

In the article by Valori,I am assuming that the article is indeed focusing on a voyage around the irritable bowel syndrome (IBS) in its various guises. Those phenotypes of which, I recognise and deliberately categorise (which in itself helps the patient from the outset), are:

  • Diarrhoeal

  • Constipating

  • Alternating

  • Pure recurrent abdominal pain

I respond to the current article because it addresses one of the more challenging aspects of a time-constrained gastroenterological consultation from a perspective assuming that there is indeed nothing wrong. This is a far cry from ‘unexplained’ abdominal symptoms. Irritable bowel is a disease in its own right affording respect, and, of course, we should not need reminding that even the hysteric will inevitably develop organic disease.

Winning the patient's confidence is fundamental; you are the expert in conventional medical gastroenterology. My experiences with the initial, pivotal, luxurious 20-minute consultation are that a focused approach …

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