Macrophages are highly heterogeneous tissue-resident immune cells that perform a variety of tissue-supportive functions. The current paradigm dictates that intestinal macrophages are continuously replaced by incoming monocytes that acquire a pro-inflammatory or tissue-protective signature. Here, we identify a self-maintaining population of macrophages that arise from both embryonic precursors and adult bone marrow-derived monocytes and persists throughout adulthood. Gene expression and imaging studies of self-maintaining macrophages revealed distinct transcriptional profiles that reflect their unique localization (i.e., closely positioned to blood vessels, submucosal and myenteric plexus, Paneth cells, and Peyer's patches). Depletion of self-maintaining macrophages resulted in morphological abnormalities in the submucosal vasculature and loss of enteric neurons, leading to vascular leakage, impaired secretion, and reduced intestinal motility. These results provide critical insights in intestinal macrophage heterogeneity and demonstrate the strategic role of self-maintaining macrophages in gut homeostasis and intestinal physiology.

Up to 20% of the global population develops gastrointestinal symptoms following a meal 1 , leading to decreased quality of life, significant morbidity and high medical costs. Although the interest of both the scientific and lay community has increased dramatically with the worldwide introduction of gluten-free and other diets, the underlying mechanisms leading to food-induced abdominal complaints remain largely unknown. Here we show that a bacterial infection and bacterial toxins can trigger an immune response leading to the production of dietary antigen-specific IgE antibodies in mice, a mechanism confined to the intestine. Subsequent oral ingestion of the respective dietary antigen results in increased visceral pain via an IgE-and mast cell-dependent mechanism. This aberrant pain signaling results from histamine receptor H1 (H1R)-mediated sensitization of visceral afferents. Moreover, in patients with irritable bowel syndrome (IBS), we show that injection of food antigens (gluten, wheat, soy and milk) into the rectosigmoid induces local edema and mast cell activation. Hence, we have unveiled and characterized a novel peripheral mechanism underlying food-induced abdominal pain, which creates new opportunities for the treatment of IBS and related abdominal pain disorders. MAIN TEXT:The mucosal immune system provides a balanced response to pathogens and harmless commensal bacteria or food antigens, thereby limiting unnecessary inflammation and concomitant tissue damage 2 . This is achieved by an active suppression of cellular and humoral responses to orally administered antigens, a mechanism referred to as oral tolerance 3 . Viral and bacterial infections can, however, interfere with tolerance to dietary antigens, thereby perturbing intestinal homeostasis 4 . An infectious gastroenteritis is a significant risk factor to develop IBS, defined as a constellation of abdominal pain and altered bowel patterns. Between 3 and 36% of enteric infections lead to new onset IBS 5 , while up to 17% of IBS patients report that their symptoms started Supplementary information included as a separate pdf file and videos (Supplementary Information Video 1-4). EXTENDED DATA LEGENDS: Extended Data Fig. 1. Extended analysis of the OVA-specific immune response and VHS in postinfectious mice. a, b, diarrhea development quantification by (a) water content in feces and (b) whole-gut transit time upon gavage of carmine red dye in OVA/sham + OVA, OVA/infected + OVA (n = 10/group) mice. c, quantification of OVA-specific IgE in intestinal homogenates of OVA/sham + OVA, saline/infected + OVA,

ObjectivesVagus nerve stimulation (VNS), most likely via enteric neurons, prevents postoperative ileus (POI) by reducing activation of alpha7 nicotinic receptor (α7nAChR) positive muscularis macrophages (mMφ) and dampening surgery-induced intestinal inflammation. Here, we evaluated if 5-HT4 receptor (5-HT4R) agonist prucalopride can mimic this effect in mice and human.DesignUsing Ca2+ imaging, the effect of electrical field stimulation (EFS) and prucalopride was evaluated in situ on mMφ activation evoked by ATP in jejunal muscularis tissue. Next, preoperative and postoperative administration of prucalopride (1–5 mg/kg) was compared with that of preoperative VNS in a model of POI in wild-type and α7nAChR knockout mice. Finally, in a pilot study, patients undergoing a Whipple procedure were preoperatively treated with prucalopride (n=10), abdominal VNS (n=10) or sham/placebo (n=10) to evaluate the effect on intestinal inflammation and clinical recovery of POI.ResultsEFS reduced the ATP-induced Ca2+ response of mMφ, an effect that was dampened by neurotoxins tetrodotoxin and ω-conotoxin and mimicked by prucalopride. In vivo, prucalopride administered before, but not after abdominal surgery reduced intestinal inflammation and prevented POI in wild-type, but not in α7nAChR knockout mice. In humans, preoperative administration of prucalopride, but not of VNS, decreased Il6 and Il8 expression in the muscularis externa and improved clinical recovery.ConclusionEnteric neurons dampen mMφ activation, an effect mimicked by prucalopride. Preoperative, but not postoperative treatment with prucalopride prevents intestinal inflammation and shortens POI in both mice and human, indicating that preoperative administration of 5-HT4R agonists should be further evaluated as a treatment of POI.Trial registration numberNCT02425774.

Abdominal VNS is feasible and safe in humans and has anti-inflammatory properties. As abdominal VNS improves POI similar to cervical VNS in mice, our data indicate that peroperative abdominal VNS may represent a novel approach to shorten POI in man.

Our study reveals a critical role for monocyte-derived MΦs in restoring intestinal homeostasis after surgical trauma. From a therapeutic point of view, our data indicate that inappropriate targeting of monocytes may increase neutrophil-mediated immunopathology and prolong the clinical outcome of POI, while future therapies should be aimed at enhancing MΦ physiological repair functions.