Introduction

The low FODMAP diet (LFD) is an efficacious dietary intervention for reducing symptoms in patients with irritable bowel syndrome (IBS). Although effective, the LFD is complex, requires guidance from a trained dietitian and may be associated with decreased caloric intake and weight loss. A less strict diet intervention, by a self-guided smartphone application (FODMAP-light DOMINO app), showed superiority compared to standard medical therapy in primary care IBS patients¹. The efficacy of the FODMAP-light app in tertiary care patients has not been evaluated.

Aims & Methods

We aim to evaluate the efficacy of the FODMAP-light app for managing IBS in tertiary care. To this end, we assessed its impact on IBS symptoms, nutritional intake and psychosocial comorbidities.
After a two-week baseline period, IBS patients were instructed to follow the FODMAP-light diet app during eight weeks. A symptom diary, including the Bristol stool scale (BSS), was filled out daily. IBS symptoms were scored on a 0-100mm Likert scale. Stool consistency was reported as days per BSS types (1-7) over two weeks. Seven-day food diaries were collected during baseline and diet period. Questionnaires to assess IBS symptom severity (IBS-SSS) and psychosocial comorbidities (PHQ and GAD-7) were filled out at baseline and after diet. Data are reported as mean±SD or median (IQR).

Results

Among 53 patients with IBS (81% female, age 32 (28-42) years, BMI 23 (20-29) kg/m²), the diet significantly reduced IBS-SSS (287±72 vs. 172±91, p < 0.0001) with an 81% responder rate (≥50 points improvement). Compared to baseline, duration (41 (30-54) vs. 17 (7-31)) and severity (39 (26-52) vs. 14 (6-33)) of abdominal pain, bloating (44 (27-55) vs. 19 (8-31)), flatulence (46 (29-57) vs. 18 (9-30)), and impact on daily life (38 (24-51) vs. (16 (6-37)), significantly improved during the diet (all p < 0.0001). Stool frequency remained unchanged, but there was a significant shift from loose (BSS type 6 and 7) to normal stools (BSS type 2,3 and 4) (p < 0.0001), and episodes of urgency significantly decreased (p < 0.01). Nutritional analysis, shown in table 1, revealed a decreased caloric intake (∆-186.1 kcal/d, p < 0.0001), but no weight loss. Intake of FODMAPs decreased significantly, except for lactose and mannitol. Psychosocial outcomes improved significantly, with reduction in somatization (11 (8–14) vs. 8 (6-12), p < 0.0001), depression (5 (3–11) vs. 4 (2–6), p < 0.0001), and anxiety (6 (3–9) vs. 4 (1–6), p < 0.001).

Conclusion

The DOMINO FODMAP-light app is an effective treatment option for improving gastrointestinal as well as psychosocial factors in tertiary care IBS, providing a promising alternative to more restrictive dietary approaches.

References

1 Carbone F and Van den Houte K et al. Gut. 2022

Introduction

Confocal laser endomicroscopy (CLE) can detect acute duodenal epithelial disruption in response to food application, potentially identifying personalized elimination diets (1). A pilot study in functional dyspepsia (FD) showed that the 6-food elimination diet (6FED) provided symptom relief. (2). Earlier research in FD, however, showed that the high rate of acute food-induced mucosal alterations on CLE were not associated with altered permeability or changes in mast cell activation ex vivo (3).

Aims & Methods

To evaluate a personalized elimination diet in patients living with FD based on results of CLE, assessing duodenal mucosal changes to locally applied food solutions from the 6FED.
A randomized, double-blind, cross-over, sham-controlled trial was conducted in 17 Rome IV FD patients, in whom immunoglobulin E (IgE) sensitization to nutrients was excluded via food-specific serum IgEs. Baseline symptoms were assessed using the Leuven Postprandial Distress Scale (LPDS) and Patient Assessment of GI Disorders–Symptom Severity Index (PAGI-SYM). Index upper GI endoscopy (EGD) was followed at least 2 weeks later by an EGD with CLE. During CLE, duodenal mucosa was visualized at baseline and after consecutive, random administration of egg white, soy, milk, wheat, lyophilized fish/shellfish and nuts solutions. In case of a reaction to the first 2 food solutions, an additional CLE was scheduled. All patients underwent a crossover dietary intervention excluding foods to which they tested positively (real diet, RD) and negatively (sham diet, SD) in random order. Following 4 weeks of diet, LPDS and PAGI-SYM scores were reevaluated. Missing data were considered non-responder, based on an extreme case approach. Data are reported as mean ± SEM. Comparisons were done using a paired t-test or related-Samples Wilcoxon test, as applicable. Response rate was evaluated using a McNemar test. P<.05 is considered significant.

Results

Dietary outcome was available from 17 patients (age 35±3.7y, 16 female, BMI 22±0.7 kg/m2). In 7% of exams (n=2), acute alterations were already present at baseline. Twelve patients (71%) underwent a second CLE procedure. One patient dropped out after the first diet (which was RD). Three patients did not have a reliable RD/SD comparison due to non-response (n=1) or early response on CLE (n=2), underwent a standardized control diet, and were excluded from the analysis. Among the 14 patients in the cross-over dietary intervention, the proportion with a clinically significant 0.7 decrease in LPDS was similar for both diets (RD 4/14 vs. SD 2/14, p=0.41). No significant differences were found in LPDS subdomains or in the total PAGI-SYM score or PAGI-SYM fullness domain between the two diets (all p>.05).

Conclusion

In patients with FD, without systemic IgE-sensitization, CLE visualized a high rate of acute, food-induced, mucosal alterations, which could not be translated in symptom benefit following a dietary intervention excluding these foods vs. foods that did not trigger a reaction in this double-blind, controlled diet intervention study. None of the analyzed clinical outcome measures differed between the two diets. Given the results of this first double-blind controlled diet intervention in patients living with FD, CLE-based diets cannot be recommended in this population.

References

1. Fritscher-Ravens A, Schuppan D, Ellrichmann M, Schoch S, Rocken C, Brasch J, et al. Confocal endomicroscopy shows food-associated changes in the intestinal mucosa of patients with irritable bowel syndrome. Gastroenterology. 2014;147(5):1012-20 e4.
2. Schol J, Vanuytsel T, Routhiaux K, Huang I, Balsiger L, Van Den Houte K, et al. The six-food elimination diet improves symptoms of functional dyspepsia. Submitted for publication. 2025.
3. Van de Bruaene C, Schol J, Balsiger L, Raymenants K, Toth J, Farre R, et al., editors. Observation of local, food-induced changes of the duodenal mucosa in functional dyspepsia cannot be translated in permeability alterations or changes in mast cell activation ex vivo. F; 2024; Bangkok, Thailand: Neurogastroenterology And Motility.

Introduction

Anti-mitochondrial antibodies (AMA) are commonly associated with Primary Biliary Cholangitis (PBC), a progressive liver disease. However, the clinical significance of AMA positivity in patients with normal liver enzymes remains poorly understood. Despite the presence of AMA, many patients maintain normal liver function, raising the question of whether these individuals are at risk for developing liver-related complications.

Aims & Methods

This study aims to evaluate the natural history, prognostic implications, and potential risk factors for disease progression in AMA-positive patients with normal liver enzymes.
A retrospective cohort study was conducted using a national healthcare database to identify patients (aged>18) with a positive AMA and normal liver enzymes between 2002 and 2023. Demographics, biochemical parameters, and liver-related complications were analyzed. Multivariate regression models assessed predictors of disease progression.

Results

Among 1,018 patients, 76 (7.5 %) developed Primary biliary cholangitis (PBC), and 30 (2.9%) progressed to cirrhosis over a median follow-up of 6.3 years. Liver-related complications were rare, with esophageal varices in 1.1%, ascites in 1.8%, hepatocellular carcinoma in 0.2%, and liver transplantation in 0.1%. Notably, higher AMA titers were strongly associated with increased risk of developing PBC, cirrhosis and liver-related complications, demonstrating a clear titer-dependent pattern.

Conclusion

Most AMA-positive patients with normal liver enzymes do not develop clinically significant liver disease. However, higher AMA titers identify a high-risk subgroup that warrants closer monitoring. These findings underscore the need for risk-stratified follow-up strategies and may influence future clinical guidelines.

Introduction

Food is often reported as a trigger for symptoms in patients with irritable bowel syndrome (IBS). One of the proposed pathophysiological mechanisms is a local immune response to food antigens, triggered by a preceding infection¹.

Aims & Methods

This study aimed to investigate rectal mucosal reactions to food in patients with IBS. Therefore, patients with IBS and food-related symptoms were included. Allergies to the food items that were tested during the colonoscopic antigen provocation (COLAP) were excluded by an allergologist. The COLAP was started in the absence of macroscopic abnormalities during sigmoidoscopy. A 200 μL solution of each food antigen (wheat, gluten, soy, and milk; administered in a randomized order and blinded), a negative control (NaCl 0.9%), and a positive control (histamine) were injected in the rectal mucosa, with a positive reaction defined as mucosal edema 12 minutes after injection and judged based on a previously used semiquantitative scale ². The reaction was independently judged by two endoscopists, resulting in a positive or negative reaction when they agreed and doubtful when they did not.

Results

Data from ten patients were available for this interim analysis. Nine were female, with a median age of 45 [range 24-58] years, and a median IBS symptom severity score of 356 [range 197-416], i.e. in the moderate to severe range. Six patients had predominant constipation, one predominant diarrhea, and three mixed bowel habits. COLAP was positive in seven patients, with a positive reaction for one food antigen in three patients and for two food antigens in four patients. In the other three patients, the test was only doubtful for one of the food antigens (n=2), or negative for all (n=1). A positive reaction to gluten was observed in five patients, to soy in three, to wheat in two, and to milk in one (Table). The reaction to histamine was positive in eight patients, with no positive reaction after injection of the negative control in all.

Conclusion

A local intestinal reaction to food antigens was seen in a subset of patients with IBS. Further research will focus on underlying pathophysiological mechanisms and clinical relevance of these findings.

References

1. Aguilera-Lizarraga J, Florens MV, Viola MF, Jain P, Decraecker L, Appeltans I, et al. Local immune response to food antigens drives meal-induced abdominal pain. Nature. 2021;590(7844):151-6.
2. Bischoff SC, Mayer J, Wedemeyer J, Meier PN, Zeck-Kapp G, Wedi B, et al. Colonoscopic allergen provocation (COLAP): a new diagnostic approach for gastrointestinal food allergy. Gut. 1997;40(6):745-53.