“IBS affects 5% to 9% of the adult population, is a common complaint causing patients to seek advice from a healthcare provider, and is a frequent source of referrals to gastroenterologists,” explains Brian E. Lacy, PhD, MD, FACG. “The reduction in quality of life that comes with IBS is as significant as moderate depression. IBS also imposes a significant negative economic burden to healthcare systems worldwide.”
With the above in mind, in The American Journal of Gastroenterology, Dr. Lacy and colleagues presented the first-ever American College of Gastroenterology (ACG) clinical guideline for the management of IBS. Advances in diagnostic testing and therapeutic options for patients with IBS led to the development of the clinical guideline, according to Dr. Lacy.
IBS Is One of the Best Studied Gut-Brain Disorders
“IBS is one of the best studied disorders of gut-brain interaction, although a number of unanswered questions and issues persist,” he says. “The management of IBS has been examined in previous reviews and position statements; however, these publications did not formally evaluate critical diagnostic and treatment recommendations using GRADE, the most rigorous methodology available. Our study team scoured the literature and identified 25 key questions they deemed most pertinent to clinicians (Table).” Dr. Lacy highlights key diagnostic and treatment recommendations in the guideline that will have the most impact for clinicians:
- Serologic testing to rule out celiac disease in patients with IBS presenting with diarrhea.
- Fecal calprotectin (or fecal lactoferrin) and C-reactive protein checks for patients with suspected IBS presenting with diarrhea to rule out IBD, which can masquerade as IBS.
- No routine colonoscopy for patients younger than 45 with IBS symptoms who do not present with warning signs. If empiric therapy fails, however, or if symptoms persist or warning signs develop, colonoscopy may be appropriate.
- A positive diagnostic strategy in place of a diagnostic strategy of exclusion, in order to improve cost-effectiveness.
Improving the Health & Well-Being of Patients With IBS
“In terms of treatment recommendations, we concur that it is just as important to recommend what should not be done as what should be done,” says Dr. Lacy. “Based on a lack of strong data to support improvement in global IBS symptoms, we do not recommend routinely using smooth muscle antispasmodics, probiotics, or polyethylene glycol. We found sufficient evidence to support the use of a low FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, polyols) diet, chloride channel activators, guanylate cyclase activators, and rifaximin. We recommend that tricyclic antidepressants be used to treat global symptoms of IBS.”
Dr. Lacy believes the ACG Guideline will help clinicians with the daily management of their patients with IBS. “With key diagnostic and therapeutic questions addressed, there is ample new clinically important information for providers at all levels of training and experience,” he says. “Although we couldn’t cover every facet of IBS diagnostic and therapeutic care, we are confident that we provided sufficient information that will enable providers to improve the health and well-being of their patients who struggle with IBS.”
There remains much to explore in the study of IBS, and other disorders of gut-brain interaction, Dr. Lacy notes. “For example, where do pain signals in IBS originate and why do they vary so widely among patients?” he asks. “Why do some patients with a gastrointestinal infection recover quickly, while others develop post-infection IBS? Why do some patients respond well to certain medications, while others with identical symptoms see minimal improvement? We clearly have a lot to learn about IBS, but that challenge is what makes this field so exciting.”