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    Management of Irritable Bowel Syndrome (beta)

    Official guideline of the American College of Gastroenterology.

    Strength
    Strong recommendation
    Consensus recommendation
    Strong/conditional recommendation
    Conditional recommendation
    Evidence
    High quality evidence
    Moderate quality evidence
    Low quality evidence
    Very low quality evidence
    Very low, moderate quality evidence
    Unable to assess quality of evidence

    Rule-out

    Celiac Disease
    1. We recommend that serologic testing be performed to rule out celiac disease in patients with IBS and diarrhea symptoms.
    IBD
    1. We suggest that fecal calprotectin (or fecal lactoferrin) and C-reactive protein be checked in patients without alarm features and with suspected IBS and diarrhea symptoms to rule out inflammatory bowel disease. moderate quality of evidence for C-reactive protein and fecal calprotectin.

    Testing

    Stool Testing
    1. We recommend against routine stool testing for enteric pathogens in all patients with IBS.
    Colonoscopy
    1. We recommend against routine colonoscopy in patients with IBS symptoms younger than 45 years without warning signs.
    Food Allergies
    1. We do not recommend testing for food allergies and food sensitivities in all patients with IBS unless there are reproducible symptoms concerning for a food allergy.
    Anorectal Physiology
    1. We suggest that anorectal physiology testing be performed in patients with IBS and symptoms suggestive of a pelvic floor disorder and/or refractory constipation not responsive to standard medical therapy.

    Diagnostic Strategy

    Diagnostic Strategy
    1. We suggest a positive diagnostic strategy as compared to a diagnostic strategy of exclusion for patients with symptoms of IBS to improve time to initiate appropriate therapy.
    2. We recommend a positive diagnostic strategy as compared to a diagnostic strategy of exclusion for patients with symptoms of IBS to improve cost-effectiveness.

    IBS Categorization

    IBS Categorization
    1. We suggest that categorizing patients based on an accurate IBS subtype improves patient therapy.

    IBS Subtypes

    Global IBS
    1. We recommend a limited trial of a low FODMAP diet in patients with IBS to improve global IBS symptoms.
    2. We suggest that soluble, but not insoluble, fiber be used to treat global IBS symptoms.
    3. We recommend against the use of antispasmodics for the treatment of global IBS symptoms.
    4. We suggest the use of peppermint to provide relief of global IBS symptoms.
    5. We suggest against probiotics for the treatment of global IBS symptoms.
    6. We recommend that tricyclic antidepressants be used to treat global symptoms of IBS.
    7. We suggest that gut-directed psychotherapies be used to treat global IBS symptoms.
    8. Using currently available evidence, we recommend against the use of fecal transplant for the treatment of global IBS symptoms.
    IBS-C
    1. We suggest against PEG products to relieve global IBS symptoms in those with IBS-C.
    2. We recommend the use of chloride channel activators to treat global IBS-C symptoms.
    3. We recommend the use of guanylate cyclase activators to treat global IBS-C symptoms.
    4. We suggest that the 5-HT4 agonist tegaserod be used to treat IBS-C symptoms in women younger than 65 years with ≤1 cardiovascular risk factors who have not adequately responded to secretagogues.
    IBS-D
    1. We do not suggest the use of bile acid sequestrants to treat global IBS-D symptoms.
    2. We recommend the use of rifaximin to treat global IBS-D symptoms.
    3. We recommend that alosetron be used to relieve global IBS-D symptoms in women with severe symptoms who have failed conventional therapy.
    4. We suggest that mixed opioid agonists/antagonists be used to treat global IBS-D symptoms.
    What do the icons mean?  
    Research PaperLacy BE, Pimentel M, Brenner DM, et al. Acg clinical guideline: management of irritable bowel syndrome. Am J Gastroenterol. 2021;116(1):17-44.