ACG publishes guidelines for the diagnosis and treatment of irritable bowel syndrome, including 17 "recommended" and 8 "not recommended" articles!

This article is compiled and compiled by Yimaitong, please do not reprint without authorization
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Irritable bowel syndrome (IBS) is a highly prevalent chronic disease that can severely reduce the quality of life of patients
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 In recent years, the diagnosis and treatment of IBS has made considerable progress, prompting the American College of Gastroenterology (ACG) to develop this first guideline for it
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 Through a comprehensive literature search, ACG answered the 25 most clinically interesting questions related to IBS.
The first 9 questions focused on diagnosis and examination, and the last 16 questions were suggestions for its treatment
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The development of this guideline is based on the Delphi method, and the main statements are as follows: 1.
It is recommended that patients with IBS and patients with diarrhea symptoms be subjected to serological testing to exclude celiac disease
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(Strong recommendation, moderate quality of evidence) 2.
It is recommended to check fecal calprotectin (or fecal lactoferrin) and C-reactive protein for patients with suspected IBS and diarrhea without warning signs to rule out inflammatory bowel disease
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(Check fecal calprotectin, C-reactive protein: strong recommendation, medium quality of evidence) (check fecal lactoferrin, strong recommendation, very low quality of evidence) 3.
It is not recommended to perform routine fecal intestinal pathogen inspection for all patients with IBS
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(Conditional recommendation, low quality of evidence) 4.
Routine colonoscopy is not recommended for patients under 45 years of age with IBS symptoms and no warning signs
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(Conditional recommendation, low quality of evidence) 5.
It is recommended that patients with IBS symptoms adopt a proactive diagnosis strategy, not just diagnose by excluding other diseases, so as to shorten the time to start correct treatment
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(Consensus recommendation, the scoring method cannot be used to evaluate this article) 6.
It is recommended that patients with IBS symptoms adopt a positive diagnosis strategy, not just diagnose by excluding other diseases, in order to improve cost-effectiveness
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(Strong recommendation, high quality of evidence) 7.
It is recommended to classify patients according to clear IBS subtypes to improve treatment
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(Consensus recommendation, scoring method cannot be used to evaluate this article) 8.
It is not recommended to conduct food allergy and food sensitivity testing for all patients with IBS, unless the patient has symptoms related to food allergy
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(Consensus recommendation, the scoring method cannot be used to evaluate this article) 9.
It is recommended to perform anorectal physiological function testing for patients with IBS who have symptoms suggesting pelvic floor muscle dysfunction and/or refractory constipation and who have not responded to conventional medical treatment
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Anorectal dysfunction can occur in all subtypes of IBS (IBS-D, IBS-C, and IBS-M), and the prevalence is expected to be as high as 40%
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Due to the lack of clear guidelines, most patients with IBS have not undergone routine anorectal manometry (ARM) and/or balloon expulsion test (BET) diagnostic tests
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For patients showing symptoms, if a careful rectal examination does not find obvious anorectal structural abnormalities, the possibility of pelvic floor dysfunction increases (sensitivity 75%, specificity 87%)
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Figure 1 shows the physiology of normal defecation and dyssynergic defecation (DD)
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Figure 1 Normal defecation and DD.
Although anorectal physiological testing alone may not be able to distinguish DD from IBS, it can identify obvious abnormalities that respond well to biofeedback treatment
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Considering the high prevalence of pelvic floor dysfunction in all subtypes of IBS, we recommend first using standard treatments for abdominal pain and bowel habits in IBS
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For patients with synergy disorder or pelvic floor symptoms found on rectal examination and IBS refractory to conventional treatment, it is recommended to use ARM, BET and/or defecation imaging for rectal and anal physiology to identify patients who are effective in biofeedback therapy
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The positive response of IBS patients with abdominal pain and bloating to biofeedback treatment further supports this recommendation
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(Consensus recommendation, the scoring method cannot be used to evaluate this article) 10.
It is recommended to conduct a limited low-FODMAP diet trial for patients with IBS to improve overall IBS symptoms
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(Conditional recommendation, very low quality of evidence) Eliminating fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) from the diet is a treatment for patients with IBS
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After FODMAP enters the digestive tract, it causes increased gastrointestinal water secretion and increased colonic fermentation, resulting in the production of short-chain fatty acids and gas, which can make IBS patients bloat and trigger IBS patients to produce eating-related symptoms
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 Most trials have reported the benefits of a low-FODMAP diet on some symptoms of IBS, particularly abdominal pain and bloating
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In general, a low FODMAP diet seems to be safe and will not cause serious adverse events, but long-term excessive FODMAP restriction may lead to micronutrient deficiencies
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 At the same time, considering the time and resources required to provide patients with consultation during the three stages of the low-FODMAP diet, it is difficult to correctly guide the low-FODMAP diet to strictly follow the dietary requirements
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 (The first stage: only eat low FODMAP food; the second stage: re-intake food while monitoring the patient’s symptoms; the third stage: take a personalized diet-avoid eating food that triggers symptoms) 11.
It is recommended to use soluble fiber (Insoluble fiber is not recommended) Treat overall IBS symptoms
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(Strong recommendation, moderate quality of evidence) 12.
Antispasmodics are not recommended to treat overall IBS symptoms
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(Conditional recommendation, low quality of evidence) 13.
It is recommended to use peppermint to relieve overall IBS symptoms
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(Conditional recommendation, low quality of evidence) 14.
Probiotics are not recommended to treat overall IBS symptoms
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(Conditional recommendation, the quality of the evidence is very low) 15.
It is not recommended to use PEG products to relieve the overall IBS symptoms of IBS-C patients
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(Conditional recommendation, low quality of evidence) 16.
It is recommended to use chloride channel activators to treat overall IBS-C symptoms
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 (Strong recommendation, moderate quality of evidence) 17.
It is recommended to use guanylate cyclase agonists to treat overall IBS-C symptoms
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 (Strong recommendation, high quality of evidence) 18.
It is recommended to use 5-HT4 agonist tegaserod to treat IBS-C female patients under 65 years of age with cardiovascular risk factors ≤1 and poor response to secretagogues
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(Strong/conditional recommendation, low quality of evidence) Tegaserod is the only 5-HT4 receptor agonist approved by the FDA for the treatment of IBS-C in adult women under 65 years of age.
1 patient with cardiovascular risk factors
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 19.
It is not recommended to use bile acid chelator to treat overall IBS-D symptoms
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(Conditional recommendation, very low quality of evidence) 20.
Rifaximin is recommended to treat overall IBS-D symptoms
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(Strong recommendation, moderate quality of evidence) 21.
Alosetron is recommended to relieve the overall symptoms of IBS-D in female patients with severe symptoms and failure of traditional treatment
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(Conditional recommendation, low quality of evidence) 22.
It is recommended that mixed opioid receptor agonists-antagonists be used to treat IBS-D symptoms
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(Conditional recommendation, moderate quality of evidence) 23.
It is recommended to use tricyclic antidepressants to treat the overall symptoms of IBS
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(Strong recommendation, moderate quality of evidence) 24.
It is recommended to use gut-oriented psychotherapy to treat overall IBS symptoms
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(Conditional recommendation, the quality of the evidence is very low) 25.
Based on the available evidence, fecal transplantation is not recommended to treat overall IBS symptoms
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(Strong recommendation, very low quality of evidence) Yimaitong compiled from: Lacy BE, Pimentel M, Brenner DM, et al.
ACG Clinical Guideline: Management of Irritable Bowel Syndrome[J].
Am J Gastroenterol.
2021 Jan 1;116 (1):17-44.
doi: 10.
14309/ajg.
0000000000001036.