First Clinical Guideline on Management of Irritable Bowel Syndrome by ACG

The American College of Gastroenterology (ACG) has announced the publication of its first-ever ACG Clinical Guideline on the Management of Irritable Bowel Syndrome (IBS), which was published online ahead-of-print in The American Journal of Gastroenterology. The guideline provides clinical recommendations for both diagnostic testing and therapeutic treatments for IBS.

Irritable Bowel Syndrome (IBS), is a disorder of bowel function and sensation in which patients have changes in bowel habits such as constipation or diarrhea and abdominal pain, along with other symptoms including abdominal bloating, and rectal urgency with diarrhea. The guideline authors write that IBS is estimated to affect 4.4%-4.8% of the population, according to Rome IV diagnostic criteria, and more commonly affects women than men.

"We are very proud to release the first ever ACG Clinical Guideline on IBS. We identified 25 clinically important questions that clinicians frequently ask and then used GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology to carefully and critically evaluate the data. We believe that these new IBS guidelines can be effectively used in daily practice to help expedite care and to improve symptoms in patients with IBS," said guideline co-author Brian E. Lacy, MD, PhD, FACG.

The guideline, jointly authored by Brian E. Lacy, PhD, MD, FACG; Mark Pimentel, MD, FRCPC; Darren M. Brenner, MD, FACG; William D. Chey, MD, FACG; Laurie Keefer, PhD; Millie D. Long, MD, MPH, FACG; and Baha Moshiree, MD, FACG, provides 25 recommendations, including:

"When creating the ACG clinical practice guideline on irritable bowel syndrome, we wanted to do more than regurgitate the evidence on various treatment options. We made every effort to synthesize the evidence in a way that always keeps the provider and patient in mind," commented guideline co-author William D. Chey, MD, FACG.

Major recommendations include-

1.Diagnostic testing to rule out celiac disease and inflammatory bowel disease (IBD) in patients with suspected IBS and diarrhea, which is not routinely performed by many health care providers.

2.Recommending against routine colonoscopy in patients with IBS symptoms under age 45 who do not exhibit warning signs such as unintentional weight loss, older age of onset of symptoms, or family history of IBD, colon cancer, or other significant gastrointestinal disease.

3.We suggest that serologic testing be performed to rule out celiac disease in patients with IBS and diarrhea symptoms.

4. We suggest that fecal calprotectin be checked in patients with suspected IBS and diarrhea symptoms to rule out inflammatory bowel disease.

5.We recommend a limited trial of a low fermentable oligosaccharides, disacchardies, monosaccharides, polyols (FODMAP) diet in patients with IBS to improve global symptoms.

6.We recommend the use of chloride channel activators and guanylate cyclase activators to treat global IBS with constipation symptoms.

7. We recommend the use of rifaximin to treat global IBS with diarrhea symptoms.

8. We suggest that gut-directed psychotherapy be used to treat global IBS symptoms.

A key approach that the guideline recommends is a positive diagnostic strategy involving a careful history, physical examination, and limited diagnostic testing, which can substantially shorten time to appropriate therapy and be more cost-effective for patients. The guideline also recommends against some therapies that do not improve global symptoms of IBS, aiming to help providers determine the most effective and efficient treatment modalities for their patients.

Dr. Chey noted, "In addition to a comprehensive analysis of the efficacy of prescription medications for IBS, we also provide detailed discussions and recommendations on diet, over-the-counter, and behavioral treatments such as the low FODMAP diet, fiber supplements, probiotics, as well as cognitive behavioral therapy and gut directed hypnosis. By doing so, we hope to provide a roadmap for providers to provide a more holistic approach to treating patients with IBS."

The full guideline is published ahead-of-print on The American Journal of Gastroenterology website. The guideline authors, as well as outside experts, are available for comment upon request.

For further reference log on to:The American Journal of Gastroenterology: December 14, 2020 - Volume Publish Ahead of Print - Issue -

doi: 10.14309/ajg.0000000000001036