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Introduction Since 2007, after a lapse of 14 years, the British Gastroenterology Society (BSG) has finally reissued guidelines for the management of irritable bowel syndrome (IBS).
IBS is one of the most common gastrointestinal diseases in clinical practice.
This article mainly provides guidance and suggestions for the management of IBS, and the main content involves the diagnosis, evaluation and treatment of IBS.
Each recommendation is evaluated on the strength of recommendation and the level of evidence according to the GRADE system.
The main statements are shown below.
2021 BSG Guidelines: Evaluation, Diagnosis and Treatment of IBS (1) Evaluation and diagnosis of IBS Compared with the diagnostic criteria for IBS patients in secondary care (such as the Rome IV criteria), the National Institute of Health and Clinical Optimization (NICE) guidelines The definition of IBS (abdominal pain or abdominal discomfort without warning signs or symptoms, accompanied by changes in bowel habits for at least 6 months) is more practical and may be more suitable for diagnosing IBS patients in primary care (Recommendation strength: weak, Level of evidence: low).
All patients who have symptoms of IBS for the first time in primary care should have a complete blood count, C-reactive protein or red blood cell sedimentation rate, and abdominal serology.
For patients with diarrhea <45 years old, a stool calprotectin test should be performed to rule out inflammatory conditions.
Bowel disease.
If indicated, local and national guidelines should be followed for screening for colorectal cancer and ovarian cancer (Strength of recommendation: strong, level of evidence: medium).
In the absence of early warning symptoms or signs, and only abnormal blood stool detection, clinicians should make a positive diagnosis of IBS based on symptoms (Strength of recommendation: strong, level of evidence: medium).
For patients with diagnostic doubts, severe symptoms, or refractory to first-line treatment, or for some patients seeking expert advice, it is necessary to refer them to the gastroenterology department in the secondary care (Strength of recommendation: weak, level of evidence: low ).
Colonoscopy is not effective for IBS, except for patients with early warning symptoms or signs, or patients with diarrhea that suggest IBS, these patients have atypical features and/or related risk factors, which increase their risk of microscopic colitis Possibility [Female, age ≥50 years, also suffering from autoimmune diseases, night or severe watery diarrhea, diarrhea duration <12 months, weight loss or use of potential triggering drugs (including non-steroidal anti-inflammatory drugs, Proton pump inhibitors, etc.
)] (Recommendation strength: strong, evidence level: medium).
For patients with diarrhea that suggest IBS but with atypical features (such as nocturnal diarrhea or previous cholecystectomy), 23-selenium-25-homotaurocholic acid scan or serum 7α-hydroxy-4-cholesterol should be considered En-3-one to rule out bile acid diarrhea (Strength of recommendation: strong, level of evidence: low).
For patients with IBS combined with bowel disorders or fecal incontinence symptoms, anorectal physiological examination (if feasible) may be considered to select patients who may benefit from biofeedback (Strength of recommendation: weak, level of evidence: low).
For patients with typical IBS symptoms, testing for pancreatic exocrine insufficiency or hydrogen breath test cannot rule out small intestinal bacterial overgrowth or carbohydrate intolerance (Strength of recommendation: strong, level of evidence: weak).
The diagnosis of IBS, its underlying pathophysiology, and natural history of the disease should be explained to the patient, including common symptom triggers.
The concept that IBS is a gut-brain interaction disorder should be introduced, and a brief description of the gut-brain axis and how it is affected by diet, stress, cognition, behavior, and emotional response to symptoms, as well as post-infection changes (Recommended strength: Strong, evidence level: weak).
(2) The first-line treatment method recommends regular exercise for all IBS patients (Recommendation Strength: Strong, Evidence Level: Weak).
First-line dietary advice should be provided to all patients with IBS (Strength of Recommendation: Strong, Level of Evidence: Weak).
IBS patients are not recommended for IgG antibody-based food elimination diet therapy (Strength of recommendation: strong, level of evidence: moderate).
Soluble dietary fiber (such as ispaghula) is an effective way to treat the overall symptoms of IBS and abdominal pain, but insoluble dietary fiber (such as wheat bran) should be avoided because it may aggravate symptoms.
Soluble dietary fiber should start with a low dose (3-4 g/day) and gradually accumulate to avoid causing bloating (Strength of recommendation: strong, level of evidence: medium).
Low fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) diet as a second-line diet therapy is an effective way to treat the overall symptoms of IBS and abdominal pain, but its implementation should be supervised by a trained nutritionist and should be based on the patient’s Tolerability redefines FODMAP (Strength of Recommendation: Weak, Level of Evidence: Very Low).
A gluten-free diet is not recommended for patients with IBS (Strength of recommendation: weak, level of evidence: very low).
Probiotics may be an effective way to treat the overall symptoms of IBS and abdominal pain, but it is impossible to recommend a specific strain or strain.
Patients who want to try probiotic therapy can be advised to take probiotics for up to 12 weeks, and if the symptoms do not improve, the drug should be discontinued (recommendation strength: weak, evidence level: very low).
Loperamide may be an effective drug for the treatment of diarrhea in patients with IBS, but it often causes abdominal pain, bloating, nausea and constipation.
Its tolerability may limit the use of the drug.
Careful titration of the dose can avoid this situation (recommended strength: strong; evidence) Grade: very low).
Certain antispasmodics may be an effective way to treat the overall symptoms of IBS and abdominal pain.
Dry mouth, visual disturbances, and dizziness are common side effects (Strength of recommendation: weak, level of evidence: very low).
Peppermint oil may be an effective way to treat the overall symptoms of IBS and abdominal pain.
Gastroesophageal reflux is a common side effect (Strength of recommendation: weak, level of evidence: very low).
Polyethylene glycol may be an effective way to treat constipation in patients with IBS.
Abdominal pain is a common side effect (strength of recommendation: weak, level of evidence: very low).
(3) Second-line treatment methods Tricyclic antidepressants, as gut-brain neuromodulators, are effective second-line drugs for the treatment of the overall symptoms of IBS and abdominal pain.
They can be used in primary or secondary health care, but the principle of their use needs to be explained carefully.
, And the patient should be informed of its side effects.
The administration should be started from a low dose (such as 10 mg of amitriptyline once a day) and slowly titrated to the maximum dose of 30-50 mg once a day (Strength of recommendation: strong, level of evidence: moderate).
Selective serotonin reuptake inhibitors, as gut-brain neuromodulators, may be effective second-line drugs to treat the overall symptoms of IBS.
Like tricyclic antidepressants, they can be used in primary or secondary care, but the rationale for their use needs to be explained carefully, and patients should be informed of their side effects (recommendation strength: weak, evidence level: low).
Eluxadoline is a mixed opioid receptor drug, an effective second-line drug for the treatment of IBS with diarrhea in secondary care.
It is contraindicated in patients with previous sphincter of Oddi or cholecystectomy, alcohol dependence, pancreatitis, or severe liver damage.
Lack of availability may limit its use (strength of recommendation: weak, level of evidence: moderate).
Serotonin 3 receptor antagonists are effective second-line drugs for the treatment of IBS with diarrhea in secondary care.
Alosetron and ramosetron are not available in many countries.
Titration of ondansetron from 4 mg once a day to a maximum of 8 mg three times a day is a suitable alternative.
Constipation is the most common side effect.
This drug class may be the most effective for IBS with diarrhea (Strength of recommendation: weak, level of evidence: medium to high).
In secondary care, the non-absorbable antibiotic rifaximin is an effective second-line drug for the treatment of IBS with diarrhea, although its effect on abdominal pain is limited.
The drug is approved in the United States for the treatment of IBS with diarrhea, but it cannot be used for this indication in many countries (strength of recommendation: weak, level of evidence: medium).
Linaclotide is a guanylate cyclase C agonist and an effective second-line drug for the treatment of IBS with constipation in secondary care.
Although diarrhea is a common side effect, Linaclotide may be the most effective secretagogue for the treatment of IBS with constipation (Strength of recommendation: strong, level of evidence: high).
Lubiprostone is a chloride channel activator and an effective second-line drug for the treatment of IBS with constipation in secondary care.
Compared with other secretagogues, this medicine is less likely to cause diarrhea.
However, patients should be warned that nausea is a common side effect (Strength of Recommendation: Strong, Level of Evidence: Moderate).
Plecanatide is another guanylate cyclase C agonist and an effective second-line drug for the treatment of IBS with constipation in secondary care.
Diarrhea is a common side effect, and the likelihood of occurrence is no less than that of linaclotide or tenapanor.
Although the drug is approved in the United States for the treatment of IBS with constipation, it has not been used for this indication in many countries (Strength of recommendation: strong, level of evidence: high).
Tenapanor is a sodium-hydrogen exchange inhibitor and an effective second-line drug for the treatment of IBS with constipation in secondary care.
Similarly, diarrhea is a common side effect.
Although the drug is approved in the United States for the treatment of IBS with constipation, it has not been used for this indication in many countries (Strength of recommendation: strong, level of evidence: high).
Tegaserod is a serotonin 4 receptor agonist.
It is an effective second-line drug for the treatment of IBS with constipation in secondary care, but it is not available outside the United States.
Diarrhea is a common side effect (Strength of Recommendation: Strong, Level of Evidence: Moderate).
(4) Psychotherapy IBS-specific cognitive behavioral therapy may be an effective way to treat the overall symptoms of IBS (Strength of recommendation: strong, level of evidence: low).
Intestinal-oriented hypnotherapy may be an effective way to treat the overall symptoms of IBS (Strength of recommendation: strong, level of evidence: low).
Psychotherapy should be considered when symptoms do not improve after 12 months of drug treatment.
If local conditions are feasible, referral can be made at an early stage based on patient preferences (Strength of recommendation: strong, level of evidence: low).
(5) Management of severe or refractory IBS Symptoms of severe or refractory IBS should prompt timely review of the diagnosis, and further targeted research should be considered (strength of recommendation: weak, level of evidence: very low).
Severe or refractory IBS should be managed in a comprehensive multidisciplinary approach (Strength of recommendation: weak, level of evidence: very low).
Iatrogenic harm caused by opioid prescriptions, unnecessary surgery, and unproven unregulated diagnosis or treatment (for economic or reputational incentives) should be avoided (strength of recommendation: strong, level of evidence: extremely low).
For more severe symptoms, consider the combined use of gut-brain neuromodulators, and be alert to the risk of serotonin syndrome (recommendation strength: weak, evidence level: very low).
Literature index: Vasant DH, Paine PA, Black CJ, et al.
British Society of Gastroenterology guidelines on the management of irritable bowel syndrome[J].
Gut.
2021 Apr 26;gutjnl-2021-324598.
IBS is one of the most common gastrointestinal diseases in clinical practice.
This article mainly provides guidance and suggestions for the management of IBS, and the main content involves the diagnosis, evaluation and treatment of IBS.
Each recommendation is evaluated on the strength of recommendation and the level of evidence according to the GRADE system.
The main statements are shown below.
2021 BSG Guidelines: Evaluation, Diagnosis and Treatment of IBS (1) Evaluation and diagnosis of IBS Compared with the diagnostic criteria for IBS patients in secondary care (such as the Rome IV criteria), the National Institute of Health and Clinical Optimization (NICE) guidelines The definition of IBS (abdominal pain or abdominal discomfort without warning signs or symptoms, accompanied by changes in bowel habits for at least 6 months) is more practical and may be more suitable for diagnosing IBS patients in primary care (Recommendation strength: weak, Level of evidence: low).
All patients who have symptoms of IBS for the first time in primary care should have a complete blood count, C-reactive protein or red blood cell sedimentation rate, and abdominal serology.
For patients with diarrhea <45 years old, a stool calprotectin test should be performed to rule out inflammatory conditions.
Bowel disease.
If indicated, local and national guidelines should be followed for screening for colorectal cancer and ovarian cancer (Strength of recommendation: strong, level of evidence: medium).
In the absence of early warning symptoms or signs, and only abnormal blood stool detection, clinicians should make a positive diagnosis of IBS based on symptoms (Strength of recommendation: strong, level of evidence: medium).
For patients with diagnostic doubts, severe symptoms, or refractory to first-line treatment, or for some patients seeking expert advice, it is necessary to refer them to the gastroenterology department in the secondary care (Strength of recommendation: weak, level of evidence: low ).
Colonoscopy is not effective for IBS, except for patients with early warning symptoms or signs, or patients with diarrhea that suggest IBS, these patients have atypical features and/or related risk factors, which increase their risk of microscopic colitis Possibility [Female, age ≥50 years, also suffering from autoimmune diseases, night or severe watery diarrhea, diarrhea duration <12 months, weight loss or use of potential triggering drugs (including non-steroidal anti-inflammatory drugs, Proton pump inhibitors, etc.
)] (Recommendation strength: strong, evidence level: medium).
For patients with diarrhea that suggest IBS but with atypical features (such as nocturnal diarrhea or previous cholecystectomy), 23-selenium-25-homotaurocholic acid scan or serum 7α-hydroxy-4-cholesterol should be considered En-3-one to rule out bile acid diarrhea (Strength of recommendation: strong, level of evidence: low).
For patients with IBS combined with bowel disorders or fecal incontinence symptoms, anorectal physiological examination (if feasible) may be considered to select patients who may benefit from biofeedback (Strength of recommendation: weak, level of evidence: low).
For patients with typical IBS symptoms, testing for pancreatic exocrine insufficiency or hydrogen breath test cannot rule out small intestinal bacterial overgrowth or carbohydrate intolerance (Strength of recommendation: strong, level of evidence: weak).
The diagnosis of IBS, its underlying pathophysiology, and natural history of the disease should be explained to the patient, including common symptom triggers.
The concept that IBS is a gut-brain interaction disorder should be introduced, and a brief description of the gut-brain axis and how it is affected by diet, stress, cognition, behavior, and emotional response to symptoms, as well as post-infection changes (Recommended strength: Strong, evidence level: weak).
(2) The first-line treatment method recommends regular exercise for all IBS patients (Recommendation Strength: Strong, Evidence Level: Weak).
First-line dietary advice should be provided to all patients with IBS (Strength of Recommendation: Strong, Level of Evidence: Weak).
IBS patients are not recommended for IgG antibody-based food elimination diet therapy (Strength of recommendation: strong, level of evidence: moderate).
Soluble dietary fiber (such as ispaghula) is an effective way to treat the overall symptoms of IBS and abdominal pain, but insoluble dietary fiber (such as wheat bran) should be avoided because it may aggravate symptoms.
Soluble dietary fiber should start with a low dose (3-4 g/day) and gradually accumulate to avoid causing bloating (Strength of recommendation: strong, level of evidence: medium).
Low fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) diet as a second-line diet therapy is an effective way to treat the overall symptoms of IBS and abdominal pain, but its implementation should be supervised by a trained nutritionist and should be based on the patient’s Tolerability redefines FODMAP (Strength of Recommendation: Weak, Level of Evidence: Very Low).
A gluten-free diet is not recommended for patients with IBS (Strength of recommendation: weak, level of evidence: very low).
Probiotics may be an effective way to treat the overall symptoms of IBS and abdominal pain, but it is impossible to recommend a specific strain or strain.
Patients who want to try probiotic therapy can be advised to take probiotics for up to 12 weeks, and if the symptoms do not improve, the drug should be discontinued (recommendation strength: weak, evidence level: very low).
Loperamide may be an effective drug for the treatment of diarrhea in patients with IBS, but it often causes abdominal pain, bloating, nausea and constipation.
Its tolerability may limit the use of the drug.
Careful titration of the dose can avoid this situation (recommended strength: strong; evidence) Grade: very low).
Certain antispasmodics may be an effective way to treat the overall symptoms of IBS and abdominal pain.
Dry mouth, visual disturbances, and dizziness are common side effects (Strength of recommendation: weak, level of evidence: very low).
Peppermint oil may be an effective way to treat the overall symptoms of IBS and abdominal pain.
Gastroesophageal reflux is a common side effect (Strength of recommendation: weak, level of evidence: very low).
Polyethylene glycol may be an effective way to treat constipation in patients with IBS.
Abdominal pain is a common side effect (strength of recommendation: weak, level of evidence: very low).
(3) Second-line treatment methods Tricyclic antidepressants, as gut-brain neuromodulators, are effective second-line drugs for the treatment of the overall symptoms of IBS and abdominal pain.
They can be used in primary or secondary health care, but the principle of their use needs to be explained carefully.
, And the patient should be informed of its side effects.
The administration should be started from a low dose (such as 10 mg of amitriptyline once a day) and slowly titrated to the maximum dose of 30-50 mg once a day (Strength of recommendation: strong, level of evidence: moderate).
Selective serotonin reuptake inhibitors, as gut-brain neuromodulators, may be effective second-line drugs to treat the overall symptoms of IBS.
Like tricyclic antidepressants, they can be used in primary or secondary care, but the rationale for their use needs to be explained carefully, and patients should be informed of their side effects (recommendation strength: weak, evidence level: low).
Eluxadoline is a mixed opioid receptor drug, an effective second-line drug for the treatment of IBS with diarrhea in secondary care.
It is contraindicated in patients with previous sphincter of Oddi or cholecystectomy, alcohol dependence, pancreatitis, or severe liver damage.
Lack of availability may limit its use (strength of recommendation: weak, level of evidence: moderate).
Serotonin 3 receptor antagonists are effective second-line drugs for the treatment of IBS with diarrhea in secondary care.
Alosetron and ramosetron are not available in many countries.
Titration of ondansetron from 4 mg once a day to a maximum of 8 mg three times a day is a suitable alternative.
Constipation is the most common side effect.
This drug class may be the most effective for IBS with diarrhea (Strength of recommendation: weak, level of evidence: medium to high).
In secondary care, the non-absorbable antibiotic rifaximin is an effective second-line drug for the treatment of IBS with diarrhea, although its effect on abdominal pain is limited.
The drug is approved in the United States for the treatment of IBS with diarrhea, but it cannot be used for this indication in many countries (strength of recommendation: weak, level of evidence: medium).
Linaclotide is a guanylate cyclase C agonist and an effective second-line drug for the treatment of IBS with constipation in secondary care.
Although diarrhea is a common side effect, Linaclotide may be the most effective secretagogue for the treatment of IBS with constipation (Strength of recommendation: strong, level of evidence: high).
Lubiprostone is a chloride channel activator and an effective second-line drug for the treatment of IBS with constipation in secondary care.
Compared with other secretagogues, this medicine is less likely to cause diarrhea.
However, patients should be warned that nausea is a common side effect (Strength of Recommendation: Strong, Level of Evidence: Moderate).
Plecanatide is another guanylate cyclase C agonist and an effective second-line drug for the treatment of IBS with constipation in secondary care.
Diarrhea is a common side effect, and the likelihood of occurrence is no less than that of linaclotide or tenapanor.
Although the drug is approved in the United States for the treatment of IBS with constipation, it has not been used for this indication in many countries (Strength of recommendation: strong, level of evidence: high).
Tenapanor is a sodium-hydrogen exchange inhibitor and an effective second-line drug for the treatment of IBS with constipation in secondary care.
Similarly, diarrhea is a common side effect.
Although the drug is approved in the United States for the treatment of IBS with constipation, it has not been used for this indication in many countries (Strength of recommendation: strong, level of evidence: high).
Tegaserod is a serotonin 4 receptor agonist.
It is an effective second-line drug for the treatment of IBS with constipation in secondary care, but it is not available outside the United States.
Diarrhea is a common side effect (Strength of Recommendation: Strong, Level of Evidence: Moderate).
(4) Psychotherapy IBS-specific cognitive behavioral therapy may be an effective way to treat the overall symptoms of IBS (Strength of recommendation: strong, level of evidence: low).
Intestinal-oriented hypnotherapy may be an effective way to treat the overall symptoms of IBS (Strength of recommendation: strong, level of evidence: low).
Psychotherapy should be considered when symptoms do not improve after 12 months of drug treatment.
If local conditions are feasible, referral can be made at an early stage based on patient preferences (Strength of recommendation: strong, level of evidence: low).
(5) Management of severe or refractory IBS Symptoms of severe or refractory IBS should prompt timely review of the diagnosis, and further targeted research should be considered (strength of recommendation: weak, level of evidence: very low).
Severe or refractory IBS should be managed in a comprehensive multidisciplinary approach (Strength of recommendation: weak, level of evidence: very low).
Iatrogenic harm caused by opioid prescriptions, unnecessary surgery, and unproven unregulated diagnosis or treatment (for economic or reputational incentives) should be avoided (strength of recommendation: strong, level of evidence: extremely low).
For more severe symptoms, consider the combined use of gut-brain neuromodulators, and be alert to the risk of serotonin syndrome (recommendation strength: weak, evidence level: very low).
Literature index: Vasant DH, Paine PA, Black CJ, et al.
British Society of Gastroenterology guidelines on the management of irritable bowel syndrome[J].
Gut.
2021 Apr 26;gutjnl-2021-324598.
