If you've experienced ongoing digestive discomfort after a bout of food poisoning, you're not alone. Studies show that up to 85.5% of people may develop post-infection irritable bowel syndrome (PI-IBS) following acute gastroenteritis (AGE). In this article, we'll explore what these terms mean, the processes involved in transitioning from acute food poisoning to ongoing digestive issues, and some considerations for managing these symptoms.
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What is Acute Food Poisoning?
Acute food poisoning, also known as foodborne gastroenteritis, is inflammation of the stomach and intestines after consuming food or beverages contaminated with germs or other harmful substances, including bacteria, viruses, parasites, chemicals, or mycotoxins. In the United States, approximately 48 million people experience a foodborne illness annually, and about 3,000 cases result in death (24).
The table below lists common microbes that may contribute to food poisoning:
Microbes can affect food safety at various stages, including growth, harvesting, processing, storage, shipping, and preparation. Foods that may be more susceptible to microbial contamination include fresh produce, raw or undercooked animal products, unpasteurized dairy products, deli foods, and improperly canned or sealed items. The presence of harmful microbes in these foods can occur at any point in the supply chain, highlighting the importance of proper handling and preparation to support food safety. (45)
Symptoms of food poisoning typically appear quickly, within hours to a few days after consuming contaminated food. The duration of symptoms can vary, lasting from a few hours to several days. Most symptoms resolve on their own, and individuals recover without specific medical treatment. However, severe cases, especially in vulnerable populations such as the elderly, young children, and immunocompromised individuals, may require medical attention and, in some instances, hospitalization. Common symptoms of gastroenteritis include:
- Abdominal pain and cramping
- Nausea and vomiting
- Diarrhea
- Fever
- Loss of appetite
- Fatigue
Symptoms of severe gastroenteritis that may require medical attention include:
- Bloody diarrhea
- Diarrhea lasting longer than three days
- Fever over 102°F
- Vomiting so often that you cannot keep liquids down
- Signs of dehydration: infrequent urination, dry mouth and throat, dizziness
The Transition from Acute to Chronic: The Gut Connection
PI-IBS is a condition that may develop after AGE. The development of PI-IBS involves a complex interplay of factors. Following the resolution of the initial infection, some individuals experience ongoing gastrointestinal symptoms. Evidence suggests that the frequency of PI-IBS is highest after parasitic infections and lowest after viral infections. Other factors that may increase the risk of developing PI-IBS include prolonged duration of initial illness, toxicity of the infecting agent, smoking, elevated markers of mucosal inflammation, female gender, depression, hypochondriasis, adverse life events preceding the initial illness, and antibiotic treatment for AGE. (22, 38)
Multiple mechanisms have been proposed in the development of PI-IBS. Collectively, these mechanisms may trigger chronic inflammation, disrupt intestinal barrier function, and alter neuromuscular function within the gastrointestinal tract. (46)
Exposure to intestinal infection may activate chronic, low-grade systemic and mucosal inflammation. Multiple studies have observed increased expression and activation of pro-inflammatory immune markers in patients with IBS. This chronic inflammation may contribute to intestinal hyperpermeability ("leaky gut"). (22, 38)
The gut microbiome, which may become altered during AGE, appears to stay in a residual dysbiotic state after the resolution of the initial infection. Compared to controls, patients with PI-IBS have a greater abundance of Bacteroidetes bacteria and relative reductions in bacteria belonging to the Firmicutes phylum. Dysbiosis may perpetuate gastrointestinal inflammation, immune activation, and intestinal permeability. (22, 38)
Two specific antibodies have also been implicated in PI-IBS. Cytolethal distending toxin B (CdtB) is a toxin produced by bacteria that cause AGE, including Campylobacter, Salmonella, E. coli, and Shigella dysenteriae. During the acute infection, the immune system creates anti-CdtB antibodies. CdtB resembles vinculin, a protein required for healthy gut function. Because of the similar structures between CdtB and vinculin, the immune system may be tricked into producing anti-vinculin antibodies through molecular mimicry. Anti-vinculin antibodies may affect interstitial cells of Cajal (ICC) in the gastrointestinal tract, which are responsible for gastrointestinal motility. In this way, AGE may contribute to intestinal dysmotility, one of the factors that may contribute to functional gastrointestinal disorders (i.e., IBS), and exacerbate the chronic effects of acute gastrointestinal infection.
Common Chronic Symptoms Post-Food Poisoning
After experiencing food poisoning, individuals may continue to experience persistent digestive issues. Common chronic symptoms after food poisoning include those associated with irritable bowel syndrome: abdominal pain, altered bowel habits, bloating, abdominal distention, and gas. Many patients with PI-IBS present with either the diarrhea-predominant (IBS-D) or mixed subtype (IBS-M) of IBS (22). A systematic review and meta-analysis demonstrated that the risk of developing IBS symptoms may increase six-fold after AGE and remain elevated for at least 2-3 years after the initial infection. The increased risk for and the chronicity of these symptoms may be attributed to the mechanisms described above.
Functional dyspepsia is also common in patients with PI-IBS (22). Symptoms of dyspepsia may include:
- Frequent and bothersome sensation of fullness after eating
- Early satiety
- Stomach pain or burning unrelated to bowel movements
Diagnosing Post-Infectious Conditions
Diagnosing post-infectious IBS involves a comprehensive evaluation by healthcare professionals to identify and understand the persistent symptoms following an acute gastrointestinal infection. A detailed medical history is typically obtained, including information about the initial infection, the onset and nature of current symptoms, and any relevant personal or family medical history. Clinical assessments may include physical examinations and laboratory tests to rule out other potential causes of gastrointestinal symptoms.
Challenges in post-food poisoning diagnosis arise due to the diverse nature of symptoms and the lack of specific biomarkers. PI-IBS often presents with symptoms that overlap with other gastrointestinal disorders, making it difficult to establish a definitive diagnosis. As a functional gastrointestinal disorder, PI-IBS lacks observable changes to gastrointestinal anatomy; this means that most standard laboratory tests come back as normal despite the presence of symptoms.
A nuanced and patient-centered strategy is crucial to tackling the challenges associated with diagnosing these conditions, which is why functional medicine shines in addressing functional gastrointestinal disorders. Functional medicine providers employ diagnostic tools that distinguish between normal and optimal states. This approach also recognizes the significant impact of external environmental factors, such as stress, on digestive health. By assessing non-standard and functional markers of gastrointestinal health and conducting a thorough patient history that highlights factors like diet, hydration, sleep, and stress management, these providers are better equipped to identify imbalances contributing to digestive symptoms compared to their conventional counterparts.
Functional Medicine Lab Testing
An initial and routine medical evaluation for patients presenting with IBS symptoms may include CBC, CMP, CRP, fecal calprotectin, and stool culture/microscopy to rule out infectious pathogens. With severe symptoms, testing and imaging to rule out celiac disease, microscopic colitis, and inflammatory bowel disease (IBD) may also be considered. (22)
However, as mentioned above, these tests generally come back normal in patients with PI-IBS, indicating the need for additional testing that is not routinely ordered in the conventional medical setting. Functional medicine providers may order the following tests during the diagnostic evaluation of chronic digestive symptoms:
ibs-smart
Measuring anti-CdtB and anti-vinculin antibodies may help diagnose PI-IBS. The ibs-smart test by Gemelli Biotech is one panel that measures both antibodies with a single blood sample.
SIBO Breath Test
At least one-fifth of patients with IBS-D may have small intestinal bacterial overgrowth (SIBO), a condition characterized by bacterial overgrowth in the small intestine. As research has expanded our knowledge on this condition, we now understand that there are three distinct subtypes of SIBO: hydrogen-dominant SIBO, hydrogen sulfide-dominant SIBO, and intestinal methanogen overgrowth (IMO). A glucose or lactulose hydrogen breath test, both from Commonwealth Diagnostics International, can be performed by patients at home to help identify SIBO or IMO in patients with PI-IBS.
Comprehensive Stool Analysis
A comprehensive stool analysis provides a complete view into gut health to assess patient recovery from AGE and identify lingering imbalances in the gut microbiome, immune function, and digestion that may contribute to chronic digestive symptoms. These comprehensive stool tests go beyond the standard screening for infectious pathogens to measure the diversity and abundance of the beneficial gut microbes, along with screening for overgrowth of pathogenic and opportunistic bacteria, viruses, parasites, and yeast that are less commonly measured on standard stool panels.
Malabsorption
An estimated one-tenth of patients with PI-IBS may experience malabsorption syndrome, which is when the small intestine does not digest and absorb carbohydrates, fats, proteins, and/or micronutrients effectively. Along with the comprehensive stool analysis, which screens for protein and fat malabsorption, breath tests can help identify fructose, lactose, or sucrose intolerance/malabsorption.
Food Intolerances
Adverse food reactions may contribute to IBS symptoms, with up to 65% of patients with IBS reporting specific food-related symptoms. Patients with IBS commonly report that removing wheat, dairy, eggs, coffee, yeast, potatoes, and citrus from their diets may be helpful (38).
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Treatment and Management Strategies
Managing chronic digestive symptoms following food poisoning involves a multifaceted approach, addressing both the symptoms and underlying factors that may contribute to the persistence of gastrointestinal issues. Functional medicine providers customize treatment plans based on individualized patient history and lab results. The 5R gut healing protocol is a holistic approach designed to address various aspects of gut health and promote healing. The five phases, often referred to as the 5Rs, are as follows:
Remove
The first phase involves identifying and eliminating factors that may contribute to gut dysfunction and inflammation. This includes removing potential irritants such as allergenic or inflammatory foods, pathogens, environmental toxins, emotional stressors, and medications. The goal is to create an environment that minimizes stress on the digestive system. (2, 15)
Based on food testing results, a doctor may recommend an elimination diet for a minimum of four weeks.
Pharmaceutical medications or natural/herbal antimicrobial agents may be recommended to help manage pathogenic overgrowth.
Replace
In the replacement phase, the focus is on replenishing digestive enzymes that may be deficient. This could involve supplementation with hydrochloric acid, pancreatic enzymes, or bile acids to support proper digestion and nutrient absorption. By enhancing the digestive process, the body may be better equipped to extract essential nutrients from food. This phase also emphasizes using diet and supplements to replace deficient nutrients identified with testing. (2, 15)
Reinoculate
This phase aims to support a healthy balance of gut microbiota by introducing beneficial bacteria, also known as probiotics. Probiotics may help promote a diverse and resilient microbial community in the gut, supporting various aspects of digestive and overall health. This may involve taking probiotic and/or prebiotic supplements and consuming fermented foods. (2, 15, 33)
Repair
The repair phase focuses on supporting the healing of the gut lining, which may have been compromised by inflammation or damage. This phase aims to reduce intestinal permeability and create an environment conducive to healing. Supplements that may support gut mucosal integrity, such as glutamine, zinc, and DGL, may be included in the protocol. (2, 15)
Rebalance
The final phase, often called the rebalance or maintenance phase, involves adopting long-term strategies to support gut health. This includes continuing to support a diverse gut microbiota through healthy lifestyle practices, such as maintaining a balanced and nutritious diet, staying hydrated, managing stress, and exercising regularly. Regular monitoring and adjustments to the protocol may be necessary to address changing needs and support ongoing gut health. (2, 15)
The Role of Diet in Recovery
Dietary management post-food poisoning plays an important role in the recovery and maintenance of optimal gut health. Studies suggest that what we eat can influence gut health. Plant-based and anti-inflammatory diets may support a healthy microbiome, help manage pathogen growth, and enhance intestinal barrier function. Conversely, excessive red meat, simple carbohydrates, saturated/trans fats, and alcohol may have the opposite effect, potentially contributing to a leaky gut, unfavorable shifts in the microbiome, and systemic inflammation. (12)
Specific diets tailored to individual needs can significantly contribute to symptom relief and promote the restoration of digestive function. The identification and elimination of trigger foods are central to this process, as certain foods may exacerbate symptoms and hinder recovery. Elimination diets, such as the low-FODMAP diet, can effectively reduce the intake of fermentable carbohydrates that may contribute to bloating, gas, and abdominal discomfort. Spicy foods, dairy, caffeine, alcohol, and artificial sweeteners are common IBS food triggers; avoidance of these may help minimize digestive symptoms. Diets should always be customized based on cultural beliefs and food tolerance levels.
Nutritional support for gut health must also ensure an adequate intake of essential nutrients that play a role in mucosal integrity and gut microbiome health. Probiotic- and prebiotic-rich foods, including yogurt, sauerkraut, kimchi, legumes, garlic, and whole grains, may contribute to the restoration of a healthy gut microbiota. Note that these foods may exacerbate digestive symptoms until bacterial overgrowth has been addressed. (10)
Nutrients such as glutamine, zinc, omega-3 fatty acids, and vitamins A and D are known for their roles in supporting gut lining repair and reducing inflammation. The table below lists foods rich in each of these gut-supporting nutrients:
Preventing Recurrence and Promoting Gut Health
As discussed above, the final step in the 5R protocol calls for sustained gut health by adopting healthy lifestyle practices. Chronic stress, sleep disturbances, dehydration, and physical inactivity may negatively impact gut health through various mechanisms. Conversely, research suggests that regular stress management practices, adequate sleep, and exercise may support digestive function and a healthy gut microbiome and reduce symptoms of IBS.
One of the best ways to help prevent the recurrence of PI-IBS is to help prevent foodborne illness, which involves practicing good hygiene, safe food handling, and making informed choices about food. According to the FDA, these tips may help reduce the risk of foodborne illness:
- Wash hands thoroughly with soap and water before handling food, after using the bathroom, and after handling raw meat or poultry. Clean kitchen surfaces, utensils, and cutting boards by washing them with hot, soapy water.
- To help prevent cross-contamination, use separate cutting boards and utensils for raw meat, poultry, seafood, and vegetables. Store raw meat and poultry on the bottom shelf of the refrigerator to avoid drips onto other foods.
- Avoid raw or undercooked eggs, meat, and seafood. A food thermometer ensures that meat, poultry, fish, and eggs are cooked to safe internal temperatures. This may help manage harmful bacteria. Follow recommended cooking temperatures for different types of food.
- Refrigerate perishable foods promptly, ideally within two hours of purchase or preparation. Keep the refrigerator temperature at or below 40°F.
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Why Food Poisoning May Be Related To Your Digestive Symptoms
Recognizing the transition from acute food poisoning to ongoing digestive symptoms is important for understanding the potential long-term effects of AGE on gastrointestinal health. While acute symptoms may resolve, chronic issues can persist, emphasizing the need for proactive management. Individuals experiencing prolonged digestive symptoms post-food poisoning are encouraged to consult healthcare professionals for personalized guidance. Managing the long-term effects of food poisoning involves adopting a comprehensive approach, including dietary adjustments, lifestyle modifications, and potential medical interventions. By addressing these issues early and seeking professional advice, individuals can support their digestive health and mitigate the impact of lingering symptoms, helping to ensure a more sustained and robust recovery.
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