British Society of Gastroenterology guidelines for the management of irritable bowel syndrome

Reference

Vasant DH, Paine PA, Black CJ, et al. British Society of Gastroenterology guidelines on the management of irritable bowel syndrome. Gut 2021;70(7):1214-1240.

Synopsis

These guidelines from the British Society of Gastroenterology were created by a multidisciplinary panel that included primary care physicians, psychologists, dietitians, and gastroenterologists. Treatment recommendations were based on systematic reviews, and all other recommendations were based on a comprehensive review of the literature. There are dozens of recommendations; I'll outline the highlights. The guidelines advocate a pragmatic definition of irritable bowel syndrome (IBS) as at least 6 months of abdominal pain or discomfort, in association with altered bowel habits, in the absence of alarm signs or symptoms. Initial evaluation in primary care should include a complete blood count, C-reactive protein or sedimentation rate, and serology for celiac disease. For patients younger than 45 years who present with diarrhea, order a fecal calprotectin test to rule out inflammatory bowel disease. Screen for colorectal cancer in accordance with national guidelines; colonoscopy is only recommended for patients with alarm signs and symptoms or who are at increased risk for microscopic colitis (female, at least 50 years old, with comorbid autoimmune disease; weight loss; diarrhea for less than 12 months; or severe, nocturnal, or watery diarrhea). Consider testing for bile acid diarrhea in patients with nocturnal diarrhea or prior cholecystectomy. The guidelines recommend against testing for pancreatic insufficiency, small intestinal bacterial overgrowth, or carbohydrate intolerance if the symptoms are typical for IBS. First-line treatment recommendations include exercise and gradually increasing doses of soluble fiber (eg, ispaghula) but not insoluble fiber (eg, wheat bran). Consider probiotics, although the guideline doesn't recommend a specific species or dose. Consider loperamide for diarrheal symptoms; antispasmodics and peppermint oil for global symptoms, as well as abdominal pain and cramping; and polyethylene glycol for constipation. (Note that a recent POEM found no benefit to peppermint oil in a well-designed trial). Second-line drugs in primary care include tricyclic antidepressants and selective serotonin reuptake inhibitors. Other drug classes, such as medications targeting 5-HT-3 and 5-HT-4 receptors, should be prescribed after evaluation by a gastroenterologist.