Professor Nick Talley has spent 35 years building the field of neurogastroenterology, and he’d like us all to stop saying “functional”. He is one of the global top medical researchers, a distinguished Australian gastroenterologist, and educator known for his seminal work on neurogastrointestinal disorders and co-authoring classic clinical examination textbooks.

His argument is that the label sends patients and doctors looking in the wrong place. A lot of these people don’t have a brain problem, they have a duodenal one, and he makes the case for a term he prefers: neurogastrointestinal disorder. From there he takes us through the pathophysiology his group has spent years building, subtle duodenal eosinophilia that ordinary pathologists aren’t counting, an abnormal duodenal microbiome, and food antigens setting off an immune response that eventually becomes self-sustaining.

Then the practical stuff. Why he biopsies the duodenum, why he reaches for antihistamine blockade, why amitriptyline and not nortriptyline, when mirtazapine is the right call, and what he does when everything has failed. Plus when a gastric emptying study actually changes anything, why lactulose breath tests are not helpful, his approach to cyclic vomiting, and a reminder that rumination is not vomiting.

Keywords: functional dyspepsia, DGBI, neurogastroenterology, duodenal eosinophilia, eosinophilic duodenitis, gastroparesis, Rome V, amitriptyline, microbiome, cyclic vomiting, SIBO, breath testing, Nick Talley

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Chapters

00:19 Intro

03:32 Welcome Nick

04:22 What functional dyspepsia is, and why it’s probably several diseases

06:48 Rome V, and why “functional” is a terrible word

08:14 How Nick explains the diagnosis to patients

09:00 Workup and first-line treatment: scoping, routine duodenal biopsies, PPIs, tricyclics, antihistamines

13:21 Adding an antihistamine on top of a PPI

13:49 Duodenal eosinophilia: can your pathologist actually see it?

15:43 EoE and functional dyspepsia: separate pathways

17:03 Six-food elimination, biologics, and the budesonide trial

19:28 The duodenal microbiome and swallowed streptococci

22:20 Refractory disease: mirtazapine, SNRIs, quetiapine, hypnotherapy 26:01 Smoking, alcohol, NSAIDs, exercise and diet

29:08 Exclusive enteral nutrition

30:02 Gastric emptying, gastroparesis, G-POEM and rumination

33:50 Cyclic vomiting syndrome

36:39 Why amitriptyline and not nortriptyline

37:51 Breath testing: what’s useful and what’s worthless

40:39 What Nick is excited about in the next five years

44:11 A weird and wonderful therapy for IBS

46:27 A career in academic medicine

50:42 Why pharma abandoned DGBI

52:16 Wrap-up