Table 2

Summary of the main foregut gut–brain disorders, key features, management options and optimal nutrition approach

Foregut gut–brain disorder diagnosisKey featuresDiagnostic basis and testsManagement optionsOptimal nutrition approach
Oesophageal dysmotilityDifficulty swallowingAbnormalities on high resolution manometryDietary adjustment and eating behavioural modification.Oral nutritional supplements if needed. NG feeding if malnourished.
Rumination syndromeHigh pressure gastric contractions precede regurgitation/vomitingTypical history. Concurrent impedance/manometry with meal provocationDiaphragmatic breathing, baclofen, Nissens fundoplication (selected patients)Optimised effortful oral feeding, short term bridging NJ to therapies only if malnourished
Cyclical vomiting syndrome and cannabis hyperemesis syndromeBouts of hyperemesis with intervals of normality. History of migraines. Relief from hot baths.Clinical history is typical. Exclusion of other structural or central neural causesMay respond to tricyclics and migraine prophylaxis. Abstinence from cannabis.Short bouts may need parenteral fluids/electrolytes. NJ likely to be unstable and unnecessary.
Chronic nausea and vomitingLow-grade background constant nausea and vomitingClinical history and exclusion of other structural or central neural causesProkinetics, antiemetics, gut–brain neuromodulatorsOptimised effortful oral feeding, avoid NJ unless malnourished.
Functional dyspepsia and gastroparesisOverlapping spectrum of varying degrees of sensorimotor impairment of gastroduodenal functionClinical history and solid meal gastric emptying test off medication affecting gastric emptying (but not based on gastric emptying study alone)Pain management (avoid opioids), psychosocial support, buspirone, gut-brain neuromodulators including mirtazapine, pro-kinetics.If malnourished with predominantly gastric muscle failure (gastroparesis), then trial of NJ with view to longer term post-pyloric feeding tube.
CIPO and enteric (small bowel) dysmotility (ED)Non-mechanically obstructed dilated small bowel (CIPO) or significantly abnormal small bowel manometry or transit (ED)CIPO—dilated small bowel radiologically. ED—small bowel manometry or abnormal transit. Full thickness biopsy if undergoing venting surgery.Prokinetics, small intestinal bacterial overgrowth therapy, non-opioid analgesia with gut–brain neuromodulatorsCIPO more likely to need parenteral nutrition than ED which should be manageable with optimised effortful oral or enteral feed.
Centrally mediated abdominal pain and narcotic bowel syndrome (NBS)Chronic continuous abdominal pain with neuropathic features. Escalating opioid doses in NBS.Clinical history and exclusion of other causes.Non-opioid analgesics (eg, duloxetine). Opioid stabilisation and reduction. Mu-opioid antagonists.Avoid enteral tube and parenteral feeding.
Somatoform disorder/central sensitivity syndromeOverlapping multiple functional symptom syndromesPsychiatric evaluationClinical psychology/liaison psychiatry. Central neuromodulatorsAvoid iatrogenesis due to escalating invasive approaches.
Avoidant restrictive food intake disorderRestrictive and avoidant behaviours not body image driven, but anxiety, fear, food related symptom and fixed (eg, health) beliefsPsychiatric evaluation.Clinical psychology and liaison psychiatry inputIf severely malnourished may need short-term bridging enteral tube feeding to therapies but need not be post-pyloric.
  • CIPO, chronic intestinal pseudo-obstruction; ED, enteric dysmotility; NBS, narcotic bowel syndrome; NG, nasogastric; NJ, nasojejunal.