Psychosocial factors associated with j-pouch surgery for patients with IBD: a scoping review.

BACKGROUND: Ulcerative colitis and Crohn's disease are subtypes of inflammatory bowel disease: a chronic condition of unclear etiology characterized by inflammation of the small and large intestine. Inflammatory bowel disease is managed with diet, medications, and surgeries, with the most common surgery, recommended to ulcerative colitis patients being j-pouch surgery. PURPOSE: To assess the current literature concerning psychosocial factors associated with j-pouch surgery for patients with inflammatory bowel disease. METHODS: A systematic scoping review of the empirical and grey literature was conducted for original research on j-pouch surgery and psychosocial variables. Eight databases were searched: Medline, PsychInfo, CINAHL, EBM Reviews, ProQuest Dissertations and Theses Global, ResearchGate, Prospero, and PrePubMed. RESULTS: Thirty-nine articles were identified. Many studies (n = 18) adopted a case-series design, and none examined psychosocial interventions. The most popular psychosocial variables assessed were quality of life (n = 34) and those associated with sexual health and functioning (n = 9). CONCLUSIONS: Despite being an established surgical procedure, little research has examined the psychosocial implications of j-pouch surgery. As such, clinicians lack a robust understanding of how this procedure affects patients' psychiatric and social status and adaptive abilities. There is a need for high-quality research utilizing validated measures and rigorous design methodologies with control populations.

Mechanical activation of vagal afferents involves opposing cation and TREK1 currents and NO regulation.

Vagal afferents convey signals of mechanical stimulation in the gut to the brain, which is essential for the regulation of food intake. However, ion channels sensing mechanical stimuli are not fully understood. This study aimed to examine the ionic currents activated by mechanical stimulation and a possible neuro-modulatory role of nitric oxide on vagal afferents. Nodose neuronal currents and potentials, and intestinal afferent firing by mechanical stimulation were measured by whole-cell patch clamp, and in vitro afferent recording, respectively. Osmotically activated cation and two-pore domain K+ currents were identified in nodose neurons. The membrane potential displayed a biphasic change under hypotonic stimulation. Cation channel-mediated depolarization was followed by a hyperpolarization mediated by K+ channels. The latter was inhibited by l-methionine (TREK1 channel inhibitor) and l-NNA (nitric oxide synthase inhibitor). Correspondingly, mechanical stimulation activated opposing cation and TREK1 currents. NOS inhibition decreased TREK1 currents and potentiated jejunal afferent nerve firing induced by mechanical stimuli. This study suggested a novel activation mechanism of ion channels underlying adaptation under mechanical distension in vagal afferent neurons. The guts' ability to perceive mechanical stimuli is vital in determining how it responds to food intake. The mechanosensation through ion channels could initiate and control gut function.

Mechanisms of reduced leptin-mediated satiety signaling during obesity.

BACKGROUND/OBJECTIVES: Disrupted leptin signaling in vagal afferent neurons contributes to hyperphagia and obesity. Thus, we tested the hypothesis that intrinsic negative regulators of leptin signaling, suppressor of cytokine signaling 3 (SOCS3) and protein tyrosine phosphatase 1B (PTP1B) underlie dysfunctional leptin-mediated vagal afferent satiety signaling during obesity. METHODS: Experiments were performed on standard chow-fed control mice, high-fat fed (HFF), or low-fat fed (LFF) mice. SOCS3 and PTP1B expression were quantified using western blot and quantitative PCR. Nodose ganglion neuronal excitability and jejunal afferent sensitivity were measured by patch clamp and extracellular afferent recordings, respectively. RESULTS: Increased expression of SOCS3 and PTP1B were observed in the jejunum of HFF mice. Prolonged incubation with leptin attenuated nodose ganglion neuronal excitability, and this effect was reversed by inhibition of SOCS3. Leptin potentiated jejunal afferent nerve responses to CCK in LFF mice but decreased them in HFF mice. Inhibition of SOCS3 restored impaired vagal afferent neuronal excitability and afferent nerve responses to satiety mediators during obesity. Two-pore domain K+ channel (K2P) conductance and nitric oxide (NO) production that we previously demonstrated were elevated during obesity were decreased by inhibitions of SOCS3 or PTP1B. CONCLUSIONS: This study suggests that obesity impairs vagal afferent sensitivity via SOCS3 and PTP1B, likely as a consequence of obesity-induced hyperleptinemia. The mechanisms underlying leptin resistance appear also to cause a more global impairment of satiety-related vagal afferent responsiveness.

Patient-Reported Pain Distributions in Inflammatory Bowel Disease: Impact on Patient Psychosocial Outcomes.

Inflammatory bowel disease (IBD) is a painful chronic gastrointestinal disease associated with diminished quality of life. No research documents IBD body pain or the associations of pain patterns to outcomes. Objectives were to map patient body pain areas and examine the associations between pain patterns with depression, catastrophizing, pain severity, and quality of life. A cross-sectional survey was collected from consecutive tertiary-care IBD clinic patients ( n = 255). Patients were classified into three pain pattern groups (No Pain; Localized Pain Only; and Widespread Pain) with more than 40% reporting widespread pain. The Localized Pain Only and Widespread Pain groups reported pain in the abdomen, the uterus/testes, vagina/penis, bladder, and pelvis/buttock areas. The body area most often reported was the anterior abdomen for the Localized Pain Only and Widespread Pain groups, with additional endorsement of lower back and anterior thigh and knees for the Widespread Pain group. The pain versus no pain patients reported greater depressive symptoms, catastrophizing, and diminished quality of life. Patients reported a variety of pain patterns during clinic visits. Widespread pain is associated with greatest pain and poorest psychosocial outcomes.

Are psychological interventions effective in treating functional dyspepsia? A systematic review and meta-analysis.

BACKGROUND AND AIM: Functional dyspepsia (FD) is a common gastrointestinal disorder, characterized primarily by postprandial fullness or early satiety and/or pain in the epigastrium with no endoscopic evidence of disease. Psychological therapies have been adapted to the treatment of disordered gut-brain interaction such as FD. We sought to determine if psychological interventions were efficacious in providing symptom management and improving health-related quality of life in patients suffering from FD. METHODS: Data were sorted that belonged to Embase (1947 to January 2020), PsychINFO (1806 to January 2020), and Ovid MEDLINE (1946 to January 2020). Randomized controlled trials using a psychological intervention in adults meeting relevant diagnostic criteria for FD were included. Data including symptom scores and quality of life measures were extracted. A random-effect model meta-analysis with standardized mean differences was used. RESULTS: Nine randomized controlled trials were identified that met our inclusion criteria. These were small, single-centered studies and used varying psychological therapies. Three studies had a sham treatment arm, leading to a high risk of bias in the remaining studies. All the studies reported beneficial effects of psychological treatment on patient's symptoms, some of which persisted up to 1 year. Psychological intervention was associated with an improvement in global FD symptom scores (standardized differences in means -1.33, 95% confidence interval -1.97 to -0.68). CONCLUSIONS: Despite the limited data, the available evidence suggests that psychological therapy is beneficial in treating patients with FD and should be considered by treating physicians if available and patients are willing. Large well-designed, sham controlled trials are needed for this extremely common disorder.

Effect of high-fat diet on mechanosensitive transient receptor potential channel activation in vagal afferent neurons.

Mechanical stimulation of the gastrointestinal tract is an important stimulus of satiety and can be transduced by transient receptor potential (TRP) channels. Several studies have revealed attenuated vagally-mediated satiety responses including mechanosensitivity in diet-induced obesity; however, ion channels underlying this hyposensitivity have not been fully understood. This study aimed to examine the effect of chronic high-fat diet on activation of selected mechanosensitive TRP channels in vagal afferents. C57/BL6 mice were fed on either a high-fat or low-fat diet for 6-8 weeks. An increase in the intracellular calcium to hypotonic solution and activators of TRPV1, TRPV4, and TRPA1 was measured in nodose neurons using Ca2+-imaging techniques. Jejunal afferent nerve firing induced by mechanical stimulation and TRP channel agonists was measured using in vitro extracellular multiunit afferent recording. In high-fat diet-fed mice, we observed reduced calcium influx and jejunal afferent response induced by mechanical stimuli and agonists of TRPV4 and TRPA1, but not TRPV1. Our data show diet-induced obesity disrupts the activation of TRPV4 and TRPA1, at both the cellular level and the level of nerve terminals in the small intestine, which may partly explain reduced mechanosensitivity of vagal afferents and may contribute to decreased gut-brain satiety signaling in obesity.

Chronic high fat diet impairs glucagon like peptide-1 sensitivity in vagal afferents.

Dysfunction of the gut-brain axis is one of the potential contributors to the pathophysiology of obesity and is therefore a potential target for treatment. Vagal afferents innervating the gut play an important role in controlling energy homeostasis. There is an increasing evidence for the role of vagal afferents in mediating the anorexigenic effects of glucagon-like peptide-1 (GLP-1), an important satiety and incretin hormone. This study aimed to examine the effect of chronic high fat diet on GLP-1 sensitivity in vagal afferents. C57/BL6 mice were fed either a high-fat or low-fat diet for 6-8 weeks. To evaluate gastrointestinal afferent sensitivity and nodose neurons' response to GLP-1, extracellular afferent recordings and patch clamp were performed, respectively. Exendin-4 (Ex-4) was used as an agonist of the GLP-1 receptor. C-Fos Expression was examined as an indication of afferent input to the nucleus tractus solitarius (NTS). Food intake was monitored in real-time before and after Ex-4 treatment to monitor the consequence of the high fat diet on the satiating effect of GLP-1. In high fat fed (HFF) mice, GLP-1 caused lower activation of intestinal afferent nerves, and failed to potentiate mechanosensitive nerve responses compared to low fat fed (LFF). GLP-1 increased excitability in LFF and this effect was reduced in HFF neurons. Consistent with these findings on vagal afferent nerves, GLP-1 receptor stimulation given systemically, had a reduced satiating effect in HFF compared to LFF mice, and neuronal activation in the NTS was also reduced. The present study demonstrated chronic high fat diet impaired vagal afferent responses to GLP-1, resulting in impaired satiety signaling. GLP-1 sensitivity may account for the impairment of satiety signaling in obesity and thus a therapeutic target for obesity treatment.

Examining Psychosocial Mechanisms of Pain-Related Disability in Inflammatory Bowel Disease.

Disability in inflammatory bowel disease (IBD) is under-investigated. Models theorize that disability is the result of a disease and its related impairments, limitations, and restrictions. This disablement process can be affected by psychosocial factors. Pain, depression, catastrophizing, and social support are associated with IBD-disability outcomes, but no studies have examined these factors concurrently. This study examined the role of psychosocial factors in the process of IBD disablement within the context of pain. Depressive symptoms, pain catastrophizing, and perceived social support were proposed as mediators in the relationship between pain and pain-related disability in cross-sectional and longitudinal models. Cross-sectionally, the mediation effects of depressive symptoms and pain catastrophizing, but not perceived social support, were significant. Longitudinally, depression was a significant mediator. Depressive symptoms and pain catastrophizing have mechanistic roles in the relationship between IBD patients' pain and pain-related disability and should be targets for intervention.

Inducible nitric oxide synthase-derived nitric oxide reduces vagal satiety signalling in obese mice.

KEY POINTS: Obesity is associated with disrupted satiety regulation. Mice with diet-induced obesity have reduced vagal afferent neuronal excitability and a decreased afferent response to satiety signals. A low grade inflammation occurs in obesity with increased expression of inducible nitric oxide synthase (iNOS). Inhibition of iNOS in diet-induced obese mice restored vagal afferent neuronal excitability, increased the afferent response to satiety mediators and distention of the gut, and reduced short-term energy intake. A prolonged inhibition of iNOS reduced energy intake and body weight gain during the first week, and reduced amounts of epididymal fat after 3 weeks. We identified a novel pathway underlying disrupted satiety regulation in obesity. Blocking of this pathway might be clinically useful for the management of obesity. ABSTRACT: Vagal afferents regulate feeding by transmitting satiety signals to the brain. Mice with diet-induced obesity have reduced vagal afferent sensitivity to satiety signals. We investigated whether inducible nitric oxide synthase (iNOS)-derived NO contributed to this reduction. C57BL/6J mice were fed a high- or low-fat diet for 6-8 weeks. Nodose ganglia and jejunum were analysed by immunoblotting for iNOS expression; NO production was measured using a fluorometric assay. Nodose neuron excitability and intestinal afferent sensitivity were evaluated by whole-cell patch clamp and in vitro afferent recording, respectively. Expression of iNOS and production of NO were increased in nodose ganglia and the small intestine in obese mice. Inhibition of iNOS in obese mice by pre-treatment with an iNOS inhibitor increased nodose neuron excitability via 2-pore-domain K+ channel leak currents, restored afferent sensitivity to satiety signals and reduced short-term energy intake. Obese mice given the iNOS inhibitor daily for 3 weeks had reduced energy intake and decreased body weight gain during the first week, compared to mice given saline, and lower amounts of epididymal fat at the end of 3 weeks. Inhibition of iNOS or blocking the action of iNOS-derived NO on vagal afferent pathways might comprise therapeutic strategies for hyperphagia and obesity.

Increased TASK channel-mediated currents underlie high-fat diet induced vagal afferent dysfunction.

We have previously demonstrated that satiety sensing vagal afferent neurons are less responsive to meal-related stimuli in obesity because of reduced electrical excitability. As leak K+ currents are key determinants of membrane excitability, we hypothesized that leak K+ currents are increased in vagal afferents during obesity. Diet-induced obesity was induced by feeding C57Bl/6J mice a high-fat diet (HFF) (60% energy from fat) for 8-10 wk. In vitro extracellular recordings were performed on jejunal afferent nerves. Whole cell patch-clamp recordings were performed on mouse nodose ganglion neurons. Leak K+ currents were isolated using ion substitution and pharmacological blockers. mRNA for TWIK-related acid-sensitive K+ (TASK) subunits was measured using quantitative real-time PCR. Intestinal afferent responses to nutrient (oleate) and non-nutrient (ATP) stimuli were significantly decreased in HFF mice. Voltage clamp experiments revealed the presence of a voltage-insensitive resting potassium conductance that was increased by external alkaline pH and halothane, known properties of TASK currents. In HFF neurons, leak K+ current was approximately doubled and was reduced by TASK1 and TASK3 inhibitors. The halothane sensitive current was similarly increased. Quantitative PCR revealed the presence of mRNA encoding TASK1 (KCNK3) and TASK3 (KCNK9) channels in nodose neurons. TASK3 transcript was significantly increased in HFF mice. The reduction in vagal afferent excitability in obesity is due in part to an increase of resting (leak) K+ conductance. TASK channels may account for the impairment of satiety signaling in diet-induced obesity and thus is a therapeutic target for obesity treatment. NEW & NOTEWORTHY This study characterized the electrophysiological properties and gene expression of the TWIK-related acid-sensitive K+ (TASK) channel in vagal afferent neurons. TASK conductance was increased and contributed to decreased excitability in diet-induced obesity. TASK channels may account for the impairment of satiety signaling in diet-induced obesity and thus is a promising therapeutic target.

Mechanisms of Quality of Life and Social Support in Inflammatory Bowel Disease.

Cognitive and social factors are essential considerations in inflammatory bowel disease (IBD) patient management, but existing research is limited. This study aims to expand the IBD literature by examining the relationship between social supports and QoL, while examining mechanisms in these relationships. Consenting patients attending an IBD outpatient clinic were provided a survey package (N = 164). Regressions evaluated predictors of IBD-QoL, and catastrophizing and optimism were examined as mediators between social support and IBD-QoL. Diminished IBD-QoL was predicted by younger age, greater negative spousal responses, and less perceived spousal support. Mediation models showed helplessness catastrophizing to be the lone mediator, acting as a mechanism between both negative spousal responses and perceived spousal support with IBD-QoL. Social interaction variables are associated with IBD-QoL, but patients' experience of helplessness acts to reduce their ability to benefit from social support. Patient care should consider supportive social and cognitive factors to improve IBD-QoL.

Effects of inflammation on the innervation of the colon.

Inflammatory bowel diseases (IBD) such as ulcerative colitis and Crohn's disease lead to altered gastrointestinal (GI) function as a consequence of the effects of inflammation on the tissues that comprise the GI tract. Among these tissues are several types of neurons that detect the state of the GI tract, transmit pain, and regulate functions such as motility, secretion, and blood flow. This review article describes the structure and function of the enteric nervous system, which is embedded within the gut wall, the sympathetic motor innervation of the colon and the extrinsic afferent innervation of the colon, and considers the evidence that colitis alters these important sensory and motor systems. These alterations may contribute to the pain and altered bowel habits that accompany IBD.

Sensitization of peripheral sensory nerves by mediators from colonic biopsies of diarrhea-predominant irritable bowel syndrome patients: a role for PAR2.

OBJECTIVES: This study examined whether mediators from biopsies of human irritable bowel syndrome (IBS) colons alter intrinsic excitability of colonic nociceptive dorsal root ganglion (DRG) neurons by a protease activated receptor 2 (PAR2)-mediated mechanism. METHODS: Colonic mucosal biopsies from IBS patients with constipation (IBS-C) or diarrhea (IBS-D) and from healthy controls were incubated in medium, and supernatants were collected. Small-diameter mouse colonic DRG neurons were incubated in supernatants overnight and perforated patch current-clamp recordings obtained. Measurements of rheobase and action potential discharge at twice rheobase were compared between IBS and controls to assess differences in intrinsic excitability. RESULTS: Supernatants from IBS-D patients elicited a marked increase in neuronal excitability compared with controls. These changes were consistent among individual patients but the relative contribution of rheobase and action potential discharge varied. In contrast, no differences in neuronal excitability were seen with IBS-C patient supernatants. The increased excitability seen with IBS-D supernatant was not observed in PAR2 knockout mice. A cysteine protease inhibitor, which had no effect on the pronociceptive actions of a serine protease, inhibited the proexcitatory actions of IBS-D supernatant. CONCLUSIONS: Soluble mediators from colonic biopsies from IBS-D but not IBS-C patients sensitized colonic nociceptive DRG neurons, suggesting differences between these two groups. PAR2 signaling plays a role in this action and this protease signaling pathway could provide novel biomarkers and therapeutic targets for treatment.

The long chain fatty acid oleate activates mouse intestinal afferent nerves in vitro.

Vagal afferents innervating the gastrointestinal tract serve an important nutrient-sensing function, and these signals contribute to satiety. Detection of nutrients occurs largely through the release of mediators from specialized enteroendocrine cells within the mucosa of the gastrointestinal tract. The signaling pathways leading to vagal afferent activation are not clear; however, previous in-vivo studies have implicated a role for cholecystokinin (CCK). We used an in vitro intestinal afferent extracellular recording preparation to study the effect of luminal perfusion of the long chain fatty acid oleate on mouse intestinal afferent activity. Oleate activated intestinal afferents in a concentration-dependent fashion, with an EC50 value of approximately 25 mmol/L. The L-type calcium channel blocker nicardipine attenuated the effect of oleate. Vagotomy resulted in a significant (>60%) reduction of the responses to both oleate and CCK. The CCK-1 receptor antagonist lorglumide nearly abolished responses to CCK and oleate. Our experiments therefore suggest that oleate activates intestinal afferents, with vagal afferents primarily involved; however, nonvagal fibres also contribute. The activation is dependent on CCK release, likely via activation of L-type channels on mucosal enteroendocrine cells, finally resulting in activation of CCK-1 receptors on the afferent terminals.

Histamine production by the gut microbiota induces visceral hyperalgesia through histamine 4 receptor signaling in mice.

The gut microbiota has been implicated in chronic pain disorders, including irritable bowel syndrome (IBS), yet specific pathophysiological mechanisms remain unclear. We showed that decreasing intake of fermentable carbohydrates improved abdominal pain in patients with IBS, and this was accompanied by changes in the gut microbiota and decreased urinary histamine concentrations. Here, we used germ-free mice colonized with fecal microbiota from patients with IBS to investigate the role of gut bacteria and the neuroactive mediator histamine in visceral hypersensitivity. Germ-free mice colonized with the fecal microbiota of patients with IBS who had high but not low urinary histamine developed visceral hyperalgesia and mast cell activation. When these mice were fed a diet with reduced fermentable carbohydrates, the animals showed a decrease in visceral hypersensitivity and mast cell accumulation in the colon. We observed that the fecal microbiota from patients with IBS with high but not low urinary histamine produced large amounts of histamine in vitro. We identified Klebsiella aerogenes, carrying a histidine decarboxylase gene variant, as a major producer of this histamine. This bacterial strain was highly abundant in the fecal microbiota of three independent cohorts of patients with IBS compared with healthy individuals. Pharmacological blockade of the histamine 4 receptor in vivo inhibited visceral hypersensitivity and decreased mast cell accumulation in the colon of germ-free mice colonized with the high histamine-producing IBS fecal microbiota. These results suggest that therapeutic strategies directed against bacterial histamine could help treat visceral hyperalgesia in a subset of patients with IBS with chronic abdominal pain.

Impaired intestinal afferent nerve satiety signalling and vagal afferent excitability in diet induced obesity in the mouse.

Gastrointestinal vagal afferents transmit satiety signals to the brain via both chemical and mechanical mechanisms. There is indirect evidence that these signals may be attenuated in obesity. We hypothesized that responses to satiety mediators and distension of the gut would be attenuated after induction of diet induced obesity. Obesity was induced by feeding a high fat diet (60% kcal from fat). Low fat fed mice (10% kcal from fat) served as a control. High fat fed mice were obese, with increased visceral fat, but were not hyperglycaemic. Recordings from jejunal afferents demonstrated attenuated responses to the satiety mediators cholecystokinin (CCK, 100 nm) and 5-hydroxytryptamine (5-HT, 10 µm), as was the response to low intensity jejunal distension, while responses to higher distension pressures were preserved. We performed whole cell patch clamp recordings on nodose ganglion neurons, both unlabelled, and those labelled by fast blue injection into the wall of the jejunum. The cell membrane of both labelled and unlabelled nodose ganglion neurons was less excitable in HFF mice, with an elevated rheobase and decreased number of action potentials at twice rheobase. Input resistance of HFF neurons was also significantly decreased. Calcium imaging experiments revealed reduced proportion of nodose ganglion neurons responding to CCK and 5-HT in obese mice. These results demonstrate a marked reduction in afferent sensitivity to satiety related stimuli after a chronic high fat diet. A major mechanism underlying this change is reduced excitability of the neuronal cell membrane. This may explain the development of hyperphagia when a high fat diet is consumed. Improving sensitivity of gastrointestinal afferent nerves may prove useful to limit food intake in obesity.

Afferent hypersensitivity in a mouse model of post-inflammatory gut dysfunction: role of altered serotonin metabolism.

Visceral hypersensitivity is an important clinical feature associated with irritable bowel syndrome which in some patients has been linked to prior infection. Here we employ an animal model in which transient infection leads to persistent gut dysfunction to investigate the role of altered 5-HT metabolism upon afferent mechanosensensitivity in the post-infected gut. Jejunal segments isolated from Trichinella spiralis-infected mice were used to assess 5-HT metabolism whilst afferent activity in T. spiralis-infected mice was studied by extracellular recordings from jejunal mesenteric afferent bundles and patch clamp recordings of isolated nodose ganglion neurons (NGNs). During acute infection, intestinal 5-HT content and release increased, 5-HT turnover decreased and afferent discharge in response to mechanical stimulation was attenuated. By day 28 post infection (PI), 5-HT turnover had normalized, but 5-HT content and release were still elevated. This was associated with afferent mechano-hypersensitivity, which persisted for 8 weeks PI and was susceptible to 5-HT(3) receptor blockade. NGNs from post-infected animals were more excitable than controls but their current densities in response to 2-methyl-5-HT were lower. T. spiralis infection increased mucosal 5-HT bioavailability and affected the spontaneous activity and mechanosensitivity of gastrointestinal sensory nerves. This involved an initial hyposensitivity occurring during acute infection followed by long-term hypersensitivity in the post-infectious period that was in part mediated by 5-HT acting via 5-HT(3) receptors. Functional down-regulation of 5-HT(3) receptors also occurs in the post-infected animals, which may represent an adaptive response to increased mucosal 5-HT bioavailability.

Anti-Hu antibodies activate enteric and sensory neurons.

IgG of type 1 anti-neuronal nuclear antibody (ANNA-1, anti-Hu) specificity is a serological marker of paraneoplastic neurological autoimmunity (including enteric/autonomic) usually related to small-cell lung carcinoma. We show here that IgG isolated from such sera and also affinity-purified anti-HuD label enteric neurons and cause an immediate spike discharge in enteric and visceral sensory neurons. Both labelling and activation of enteric neurons was prevented by preincubation with the HuD antigen. Activation of enteric neurons was inhibited by the nicotinic receptor antagonists hexamethonium and dihydro-ß-erythroidine and reduced by the P2X antagonist pyridoxal phosphate-6-azo (benzene-2,4-disulfonic acid (PPADS) but not by the 5-HT3 antagonist tropisetron or the N-type Ca-channel blocker ω-Conotoxin GVIA. Ca++ imaging experiments confirmed activation of enteric neurons but not enteric glia. These findings demonstrate a direct excitatory action of ANNA-1, in particular anti-HuD, on visceral sensory and enteric neurons, which involves nicotinic and P2X receptors. The results provide evidence for a novel link between nerve activation and symptom generation in patients with antibody-mediated gut dysfunction.