Why the Stomach Won't Settle
Dr. Rick's Picks, Issue 002: one practice, one paper, one product, one person
A weekly read on the gut, the brain, and the wiring in between. One clinical pearl, one paper, one product, one person. No hype, no selling, just the stuff I actually think about.
1. Practice
The patient who’s full after four bites, and the workup that comes back clean.
This one shows up constantly. Someone eats a normal meal, or less, and feels uncomfortably full within minutes. Sometimes it’s burning or gnawing pain in the upper abdomen instead, unrelated to meals. Endoscopy is normal. Bloodwork is normal. They get told it’s stress, or acid, or nothing at all.
Most of the time it’s functional dyspepsia, and “functional” here doesn’t mean not real or psychological. Rome V retired that word almost everywhere else in the gut-brain vocabulary, replacing it with DGBI, disorders of gut-brain interaction. Functional dyspepsia is one of the few terms it kept. It has earned the name: a specific, mechanistically defined diagnosis, not a placeholder for “we didn’t find anything.”
Most people get the mechanism backwards, physicians included. Functional dyspepsia is not the stomach digesting slowly. That’s gastroparesis, a different diagnosis defined by measurably delayed gastric emptying on a scan. The two overlap, but plenty of FD patients have entirely normal emptying studies. Speed isn’t the problem. Two other things are.
Gastric accommodation is the first. The stomach is supposed to relax and expand when food enters, a vagally-mediated reflex that makes room without raising pressure. In FD that reflex is blunted, so a normal meal registers as a full stomach. Visceral hypersensitivity is the second, the same story as Issue 001, different organ. Normal stretch and normal acid exposure get relayed by the enteric nervous system and read by the brain as pain that has no business being there.
Clinically this splits into two overlapping patterns. Postprandial distress syndrome is early fullness, meal-triggered. Epigastric pain syndrome is burning or gnawing pain, not necessarily tied to eating. Most patients straddle both. Guidelines recommend testing for H. pylori and treating it before settling on an FD diagnosis. In a subset of patients, clearing the infection ends the problem outright.
Treatment stays incomplete. PPIs help some. Low-dose tricyclics help some. Prokinetics help some. Nothing crosses the finish line for everyone, which is exactly why the product pick below carries more evidence than most people expect from something sold over the counter.
2. Publication
One paper worth reading, in three sentences.
The Rome V pharmacology and nutraceuticals chapter (Camilleri et al., Gastroenterology 2026;170:1152-1170) reviews the trial evidence for non-prescription options in DGBI, including peppermint oil alone in IBS and a peppermint-plus-caraway-oil combination specifically in functional dyspepsia. The FD combination trials land at a number needed to treat of about 3, which is a genuinely strong effect size for a symptom-based GI condition. It’s the paper behind this week’s product pick, not a separate tangent, so if you only read one section, read the nutraceuticals chapter.
3. Product
This week’s pick: enteric-coated peppermint oil and caraway oil, combined. Unsponsored.
Sold in the US as FDgard and under a few other names, this is the combination the Rome V pharmacology chapter is citing when it reports that NNT of about 3 for functional dyspepsia. The enteric coating matters more than people assume. Plain peppermint oil, uncoated, can relax the lower esophageal sphincter and cause reflux, which is a strange failure mode for something meant to calm the stomach. A coating that survives the stomach and releases in the small intestine avoids that problem and is what the trial data actually used.
This isn’t a cure and it isn’t for everyone with upper GI symptoms. It’s a low-risk, reasonably evidenced option worth knowing about before reaching for a prescription, and worth mentioning to your own doctor if postprandial fullness or epigastric burning is the pattern you’re dealing with.
4. Person
One person worth following in this space.
Nicholas Talley, MD, PhD, a gastroenterologist and one of the central figures behind the Rome criteria as they’ve evolved from Rome II through Rome V. Based in Australia, longtime editor-in-chief of the American Journal of Gastroenterology, and one of the researchers most responsible for functional dyspepsia being treated as a defined, mechanistically-grounded diagnosis rather than a wastebasket term. If this issue was useful, his body of work on PubMed is where the FD and IBS overlap literature actually lives.
That’s the four. See you next week.
Rick
From BellyMD
I build MGB+, a small supplement line for gut-brain support: Clear, Cool, and Calm, each a magnesium and B-vitamin based formula meant to support the gut-brain axis as part of a broader routine. Structure-function support, not a treatment for any disease. If that is relevant to you, it lives at belly-md.com.
If you want to talk through your own gut-brain picture with me directly, I offer a gut-brain consultation (educational, 500 dollars). Details at belly-md.com.
Not medical advice. This newsletter is for education and does not create a physician-patient relationship. Nothing here is a diagnosis or a prescription. Talk to your own physician before starting, stopping, or combining any medication or supplement, including over-the-counter ones.