ACG Clinical Guideline: Management of Irritable Bowel Syndrome

Abstract

Irritable bowel syndrome (IBS) is a highly prevalent, chronic disorder that significantly reduces patients' quality of life. Advances in diagnostic testing and in therapeutic options for patients with IBS led to the development of this first-ever American College of Gastroenterology clinical guideline for the management of IBS using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Twenty-five clinically important questions were assessed after a comprehensive literature search; 9 questions focused on diagnostic testing; 16 questions focused on therapeutic options. Consensus was obtained using a modified Delphi approach, and based on GRADE methodology, we endorse the following: We suggest that a positive diagnostic strategy as compared to a diagnostic strategy of exclusion be used to improve time to initiating appropriate therapy. We suggest that serologic testing be performed to rule out celiac disease in patients with IBS and diarrhea symptoms. We suggest that fecal calprotectin be checked in patients with suspected IBS and diarrhea symptoms to rule out inflammatory bowel disease. We recommend a limited trial of a low fermentable oligosaccharides, disacchardies, monosaccharides, polyols (FODMAP) diet in patients with IBS to improve global symptoms. We recommend the use of chloride channel activators and guanylate cyclase activators to treat global IBS with constipation symptoms. We recommend the use of rifaximin to treat global IBS with diarrhea symptoms. We suggest that gut-directed psychotherapy be used to treat global IBS symptoms. Additional statements and information regarding diagnostic strategies, specific drugs, doses, and duration of therapy can be found in the guideline.

Diarrhea Predominant-Irritable Bowel Syndrome (IBS-D): Effects of Different Nutritional Patterns on Intestinal Dysbiosis and Symptoms

“…Recent studies have showed that IBS patients have a worsening of symptoms after gluten/wheat ingestion so the consumption of these substances and gluten sensitivity have be considered involved in the etiology of IBS [ 103 , 104 , 105 , 106 ]; thus, a gluten-free diet is usually linked to a reduction of GI symptoms in IBS [ 92 ]. However, Guidelines 2020 recommended to verify if IBS-D patients are affected by celiac disease, performing the serological tests before giving a diet [ 9 ]. It is not clear if it is gluten that determines symptoms or other wheat components.…”

“…Based on Roma IV criteria, IBS is classified according to the predominant stool pattern, recognized using the Bristol Stool Scale [ 2 ]. There are four different subtypes of IBS [ 8 , 9 ]: Constipation predominant IBS (IBS-C): more than 25% hard stools and less than 25% loose stools. Diarrhea predominant IBS (IBS-D): more than 25% loose stools and less than 25% hard stools.…”

Systematic review and network meta‐analysis: efficacy of licensed drugs for abdominal bloating in irritable bowel syndrome with constipation

“…The precise mechanisms by which these agents improve abdominal bloating in patients with IBS‐C are unclear but may relate to improvements in gastrointestinal transit and modulation of visceral sensation, which likely differs from patient to patient. Further studies to elucidate the pathophysiological processes involved are needed, as the results may translate into better treatments for this burdensome symptom of IBS‐C 75 …”

Evaluation of the short-term efficacy of local analgesic (lidocaine) and opioid analgesic (sufentanil) on patients with centrally mediated abdominal pain syndrome: a randomized controlled trial

“… 3 Gut-directed hypnotherapy is recommended and is being increasingly applied to patients with IBS, which can achieve an effect similar to that of the low fermentable oligosaccharide, disaccharide, monosaccharide, and polyol diet; it can further be applied to inflammatory bowel disease to a lesser extent via its potential mechanism of action on the brain–gut axis. 16 – 18 Cognitive–behavioral therapy delivered by telephone or internet has also been shown superior to the usual treatment methods and is recommended for treating IBS. 19 , 20 Four classes of psychotherapy hold the most promise in CAPS: cognitive–behavioral therapy, psychodynamic interpersonal therapy, mindfulness/acceptance-based therapies and hypnotherapy, 1 although related clinical research is lacking.…”