Milking Cats

By Richard Stevens

Gastroenterology Textbooks


Patients don’t read gastroenterology textbooks. They feel symptoms and sometimes tell their doctors about them.

The doctor then pigeonholes what is presented into a diagnostic box and, if they are not sure, uses increasingly invasive and reductionist investigations to force the information into a labelled box. Ideally evidence of a structural abnormality is found; a breakage, an error that everyone can see must be the cause of the patient’s symptoms.

If no concrete cause for the symptoms is found by the doctor, the patient must be at fault. The term ‘functional’, itself newspeak for non-functioning, is used and usually in a dismissive way. Patients with ‘medically unexplained symptoms’ are often felt to be neurotic, imagining their symptoms, or mad. Which is odd because the deficiency is clearly with the medicine that can’t do the explaining.

However the old paradigm may be shifting. Increasing we hear of the gut-brain axis: the microbiome is now controlling more and more functions – and possibly even our behaviour.

Gastroenterology needs to make this area its own. Clearly gut bacteria are located in the gut and that must be GI territory. If gastroenterology does not lead on this area others will. But it may mean giving up a few deeply held beliefs and practices.

If the microbiome can act through the gut-brain axis, then some previously unidentified symptoms may soon have a medical explanation. That means anxious patients with complex interacting gut-brain psychic and somatic connections are legitimate patients. No longer oddballs with ‘medically unexplained’ symptoms, not really worthy of attention.

This new horizon was evident at our recent combined endoscopy/European meeting. Cancer, coeliac disease and colitis were all covered, but so too were nutrition and the role of diet in autism, classifying functional disorders, as well as benchmarking and educational standards.

Reception was overwhelmingly positive, although a few people always want yet-bluer sky theory. Even so, I can’t help thinking the future is on all the conditions the patient brings us … and not just those in the textbook.


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