Management of Irritable Bowel Syndrome
Official guideline of the American College of Gastroenterology.
Rule-out
Celiac Disease
We recommend that serologic testing be performed to rule out celiac disease in patients with IBS and diarrhea symptoms.
Strong recommendation
Moderate quality evidence
IBD
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.
Strong recommendation
Testing
Stool Testing
We recommend against routine stool testing for enteric pathogens in all patients with IBS.
Conditional recommendation
Low quality evidence
Colonoscopy
We recommend against routine colonoscopy in patients with IBS symptoms younger than 45 years without warning signs.
Conditional recommendation
Low quality evidence
Food Allergies
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
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
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.
We recommend a positive diagnostic strategy as compared to a diagnostic strategy of exclusion for patients with symptoms of IBS to improve cost-effectiveness.
Strong recommendation
High quality evidence
IBS Categorization
IBS Categorization
We suggest that categorizing patients based on an accurate IBS subtype improves patient therapy.
IBS Subtypes
Global IBS
We recommend a limited trial of a low FODMAP diet in patients with IBS to improve global IBS symptoms.
Conditional recommendation
Very low quality evidence
We suggest that soluble, but not insoluble, fiber be used to treat global IBS symptoms.
Strong recommendation
Moderate quality evidence
We recommend against the use of antispasmodics for the treatment of global IBS symptoms.
Conditional recommendation
Low quality evidence
We suggest the use of peppermint to provide relief of global IBS symptoms.
Conditional recommendation
Low quality evidence
We suggest against probiotics for the treatment of global IBS symptoms.
Conditional recommendation
Very low quality evidence
We recommend that tricyclic antidepressants be used to treat global symptoms of IBS.
Strong recommendation
Moderate quality evidence
We suggest that gut-directed psychotherapies be used to treat global IBS symptoms.
Conditional recommendation
Very low quality evidence
Using currently available evidence, we recommend against the use of fecal transplant for the treatment of global IBS symptoms.
Strong recommendation
Very low quality evidence
IBS-C
We suggest against PEG products to relieve global IBS symptoms in those with IBS-C.
Conditional recommendation
Low quality evidence
We recommend the use of chloride channel activators to treat global IBS-C symptoms.
Strong recommendation
Moderate quality evidence
We recommend the use of guanylate cyclase activators to treat global IBS-C symptoms.
Strong recommendation
High quality evidence
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.
Low quality evidence
IBS-D
We do not suggest the use of bile acid sequestrants to treat global IBS-D symptoms.
Conditional recommendation
Very low quality evidence
We recommend the use of rifaximin to treat global IBS-D symptoms.
Strong recommendation
Moderate quality evidence
We recommend that alosetron be used to relieve global IBS-D symptoms in women with severe symptoms who have failed conventional therapy.
Conditional recommendation
Low quality evidence
We suggest that mixed opioid agonists/antagonists be used to treat global IBS-D symptoms.
Conditional recommendation
Moderate quality evidence
What do the icons mean?
How strong is the ACG's recommendation?
Strong recommendation
Intervention's desirable effects clearly outweigh undesirable effects.Consensus recommendation
Strong/conditional recommendation
Conditional recommendation
Uncertainty in tradeoffs between desirable & undesirable effects of intervention.High quality evidence
Further research is unlikely to change the confidence in estimate of effect.Moderate quality evidence
Further research would be likely to have an impact on the confidence in the estimate of effect.Low quality evidence
Further research would be expected to have an impact on the confidence in the estimate of effect.Very low quality evidence
Any estimate of effect is very uncertain.Very low, moderate quality evidence
Very low for fecal lactoferrin, moderate for C-reactive protein and fecal calprotectin
Unable to assess quality of evidence
Literature
