Summary Background There is a growing body of evidence implicating a role for the brain‐gut axis in the pathogenesis of inflammation in patients with IBD. Aims To perform a narrative review of published literature regarding the association of the autonomic nervous system and intestinal inflammation and to describe the rationale for and emerging use of autonomic manipulation as a therapeutic agent Methods Current relevant literature was summarised and critically examined. Results There is substantial pre‐clinical and clinical evidence for a multifaceted anti‐inflammatory effect of the vagus at both systemic and local intestinal levels. It acts via acetylcholine‐mediated activation of α‐7‐acetylcholine receptors involving multiple cell types in innate and adaptive immunity and the enteric nervous system with subsequent protective influences on the intestinal barrier, inflammatory mechanisms and the microbiome. In patients with IBD, there is evidence for a sympatho‐vagal imbalance, functional enteric neuronal depletion and hyporeactivity of the hypothalamic‐pituitary‐adrenal axis. Direct or transcutaneous vagal neuromodulation up‐regulates the cholinergic anti‐inflammatory pathway in pre‐clinical and clinical models with down‐regulation of systemic and local intestinal inflammation. This is supported by two small studies in Crohn's disease although remains to be investigated in ulcerative colitis. Conclusions Modulating the cholinergic anti‐inflammatory pathway influences inflammation both systemically and at a local intestinal level. It represents a potentially underutilised anti‐inflammatory therapeutic strategy. Given the likely pathogenic role of the autonomic nervous system in patients with IBD, vagal neuromodulation, an apparently safe and successful means of increasing vagal tone, warrants further clinical exploration.

The intestinal barrier is a dynamic, semipermeable structure that simultaneously allows absorption of nutrients while protecting the host from potentially harmful effects of the luminal environment.Intestinal permeability is altered by physiological (e.g., stress) and pathological states (e.g., mucosal inflammation). There is accumulating evidence implicating intestinal barrier dysfunction as the