Fermentable Carbohydrates FODMAPs Exacerbate Functional Gastrointestinal Symptoms in Patients With Inflammatory Bowel Disease: A Randomised, Double-blind, Placebo-controlled, Cross-over, Re-challenge Trial

BACKGROUND AND AIMS: Preliminary evidence suggests that fermentable carbohydrate restriction might ameliorate functional gastrointestinal symptoms FGS in inflammatory bowel disease IBD. Our aim was to determine whether fermentable carbohydrates exacerbate FGS in IBD using a randomised, double-blinded, placebo-controlled, re-challenge trial. METHODS: Patients with quiescent IBD and FGS responsive to a low FODMAP diet were allocated to a series of 3-day d fermentable carbohydrate challenges in random order fructan, 12 g/d; galacto-oligosaccharides [GOS 6 g/d; sorbitol, 6 g/d; and glucose placebo, 12 g/d], each separated by a washout period. Symptoms and stool output were measured daily during the challenges. RESULTS: Thirty-two patients with IBD, fulfilling criteria for irritable bowel syndrome, functional bloating, or functional diarrhoea, were recruited and data were available for 29 patients completing all arms 12 Crohn's disease, 17 ulcerative colitis. Significantly fewer patients reported adequate relief of FGS on the final day day of the fructan challenge 18/29, 62.1% compared with glucose 26/29, 89.7% p = 0.033. There was greater severity of pain 1.1 vs 0.5, p = 0.004, bloating 1.3 vs 0.6, p = 0.002, flatulence 1.5 vs 0.7, p = 0.004, and faecal urgency 0.9 vs 0.4, p = 0.014 on the final day of fructan challenge compared with glucose. CONCLUSIONS: At the relatively high doses used, fructans, but not GOS or sorbitol, exacerbated FGS in quiescent IBD. Further research is required to determine whether a low FODMAP diet reduces FGS in IBD and the degree of FODMAP restriction required for symptom improvement.