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

2025 Seoul Consensus on Clinical Practice Guidelines for Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a chronic, disabling, and functional bowel disorder that significantly affects social functioning and reduces quality of life and increases social costs. The Korean Society of Neurogastroenterology and Motility published clinical practice guidelines on the management of IBS based on a systematic review of the literature in 2017, and planned to revise these guidelines in light of new evidence on the pathophysiology, diagnosis, and management of IBS. The current revised version of the guidelines is consistent with the previous version and targets adults diagnosed with or suspected of having IBS. These guidelines were developed using a combination of de novo and adaptation methods, with analyses of existing guidelines and discussions within the committee, leading to the identification of key clinical questions. Finally, the guidelines consisted of 22 recommendations, including 3 concerning the definition and risk factors of IBS, 4 regarding diagnostic modalities and strategies, 2 regarding general management, and 13 regarding medical treatment. For each statement, the advantages, disadvantages, and precautions were thoroughly detailed. The modified Delphi method was used to achieve expert consensus to adopt the core recommendations of the guidelines. These guidelines serve as a reference for clinicians (including primary care physicians, general healthcare providers, medical students, residents, and other healthcare professionals) and patients, helping them to make informed decisions regarding IBS management.

Small intestine bacterial overgrowth (SIBO) breath test does not predict symptom severity in gut-brain interaction disorders: role of anxiety, depression, and inflammatory biomarkers

BACKGROUND

The high prevalence of disorders of the gut-brain interaction (DGBI), the availability of breath tests for the diagnosis of small intestine bacterial overgrowth (SIBO) together with some confusion about the concept of SIBO are leading to an increase in the number of SIBO diagnoses.

OBJECTIVE

We aimed to analyze the factors associated with the severity of gastrointestinal symptoms in patients undergoing a SIBO breath test.

METHODS

A cross-sectional observational study including 70 patients who underwent a SIBO test with lactitol and completed questionnaires including the ROME IV criteria for Irritable Bowel Syndrome (IBS), the Irritable Bowel Syndrome Severity Score (IBSSS), and the HAD anxiety and depression scales. Additionally, blood levels of histamine, citrulline, ghrelin, Intestinal-Fatty Acid Binding Protein (I-FABP) and Transient Receptor Potential Cation Channel Subfamily V, Member 1 (TRPV-1) were measured.

RESULTS

The mean age was 45±16 years and 70% were women. Abdominal pain and/or abdominal distension were present in 85% of patients. 44% met IBS Rome IV criteria. IBSSS total score had a correlation with age (-0.354, p<0.001), HAD-A (0.391, p<0.001) and HAD-D (0.409, p<0.001) scores, and histamine levels (0.279, p=0.019). Abdominal pain correlated with levels of histamine (0.320, p<0.05; 0.282, p<0.05) and ghrelin (0.252, p<0.05, 0.347, p<0.05), while abdominal distension correlated with I-FABP levels (0.314, p<0.05). The SIBO test was positive in 75% but did not correlate with symptom severity.

CONCLUSION

We hereby unveiled some factors associated with the severity of abdominal pain and distension such as age, auto-perceived anxiety and depression and some biomarkers but not SIBO test result.

Efficacy of gut-brain neuromodulators in irritable bowel syndrome: an updated systematic review and meta-analysis

BACKGROUND

Gut-brain neuromodulators might be efficacious for irritable bowel syndrome (IBS), but there has been no synthesis of evidence from randomised controlled trials (RCTs) of some drug classes, and whether they have pain-modifying properties in IBS is unclear. We updated a previous systematic review and meta-analysis of RCTs examining these questions.

METHODS

We searched MEDLINE (from Jan 1, 1946, to Jan 1, 2025), Embase and Embase Classic (from Jan 1, 1947, to Jan 1, 2025), and the Cochrane Central Register of Controlled Trials (from database inception to Jan 1, 2025). Trials recruiting adults with IBS and that compared gut-brain neuromodulators versus placebo over at least 4 weeks of treatment were eligible. Dichotomous symptom data were pooled using a random effects model to obtain a relative risk (RR) of remaining symptomatic after therapy, with a 95% CI.

FINDINGS

The search strategy identified 3625 citations. 28 RCTs were eligible containing 2475 patients. Ten RCTs were identified since our previous meta-analysis, containing 1348 patients. The RR of global IBS symptoms not improving with gut-brain neuromodulators versus placebo in 22 RCTs (2222 patients) was 0·77 (95% CI 0·69-0·87). The best evidence in terms of persistence of global IBS symptoms was for tricyclic antidepressants (TCAs) in 11 trials (1144 patients; RR 0·70, 0·62-0·80). The RR of abdominal pain not improving with gut-brain neuromodulators versus placebo in 19 RCTs (1792 patients) was 0·72 (95% CI 0·62-0·83). The best evidence was for TCAs in seven trials (708 patients; RR 0·69, 0·54-0·87), but there was also a benefit of selective serotonin reuptake inhibitors in seven RCTs (324 patients; RR 0·74, 0·56-0·99), and serotonin and norepinephrine reuptake inhibitors in two trials (94 patients; RR 0·22, 0·08-0·59). Adverse events were not significantly more common with gut-brain neuromodulators, although rates of withdrawal due to adverse events were significantly higher. The certainty in the evidence for tricyclic antidepressants for global IBS symptoms was moderate, but it was low to very low for all other endpoints and drug classes studied.

INTERPRETATION

Some gut-brain neuromodulators are efficacious in reducing global symptoms and abdominal pain in IBS. The findings support guidelines that recommend use of tricyclic antidepressants for ongoing global symptoms or abdominal pain but also highlight a potential for SSRIs to be modestly effective for abdominal pain. More data for SNRIs, azapirones, and tetracyclic antidepressants in IBS are required.

FUNDING

None.

Efficacy of dietary interventions in irritable bowel syndrome: a systematic review and network meta-analysis

BACKGROUND

Patients with irritable bowel syndrome (IBS) are often interested in dietary interventions as a means of managing their symptoms. However, the relative efficacy of available diets for the management of IBS is unclear. We aimed to examine the relative efficacy of various dietary interventions in IBS.

METHODS

For this systematic review and network meta-analysis we searched MEDLINE, EMBASE, EMBASE Classic, and the Cochrane Central Register of Controlled Trials from database inception to Feb 7, 2025, to identify randomised controlled trials comparing an active dietary intervention requiring changes to the intake of more than one food in IBS with either a control intervention, such as a habitual diet, sham diet, a high fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet, or alternative miscellaneous dietary advice, or any other active dietary intervention requiring changes to the intake of more than one food. We assessed efficacy using dichotomous assessments of improvement in global IBS symptoms or improvement in individual IBS symptoms, including abdominal pain, abdominal bloating or distension, and bowel habit. We pooled data using a random-effects model, with the efficacy of each intervention reported as pooled relative risks (RRs) with 95% CIs. We ranked interventions according to their P-score, which measures the mean extent of certainty that one intervention is better than another, averaged over all competing interventions.

FINDINGS

We identified 28 eligible randomised controlled trials (comprising 2338 patients) of 11 different dietary interventions compared with four control interventions, of which six (low FODMAP diet, British Dietetic Association/National Institute for Health and Care Excellence [BDA/NICE] diet, lactose-reduced diet, starch-reduced and sucrose-reduced diet, a personalised diet, and a Mediterranean diet) were studied in more than one trial. For global IBS symptoms, assessed in 28 randomised controlled trials and when considering only the dietary interventions studied in more than one trial, a starch-reduced and sucrose-reduced diet ranked first (RR of global IBS symptoms not improving 0·41 [95% CI 0·26-0·67]; P-score 0·84; two trials), a low FODMAP diet ranked fourth (0·51 [0·37-0·70]; P-score 0·71; 24 trials), and a BDA/NICE diet ranked tenth (0·62 [0·43-0·90]; P-score 0·44; eight trials), versus a habitual diet. For abdominal pain, assessed in 26 trials and when considering only the dietary interventions studied in more than one randomised controlled trial, a starch-reduced and sucrose-reduced diet ranked second (RR of abdominal pain not improving 0·54 [95% CI 0·33-0·90]; P-score 0·73; two trials), and a low FODMAP diet ranked fifth (0·61 [0·42-0·89]; P-score 0·64; 23 trials), versus a habitual diet. For abdominal bloating or distension, assessed in 26 trials and when considering only the dietary interventions studied in more than one randomised trial, only a low FODMAP diet (RR of abdominal bloating or distension not improving 0·55 [95% CI 0·37-0·80]; P-score 0·64; 23 trials) was superior to a habitual diet and ranked fourth. For bowel habit, assessed in 23 randomised trials, none of the dietary interventions was superior to any of the control interventions, but a low FODMAP diet was superior to a BDA/NICE diet (RR of bowel habit not improving 0·79 [95% CI 0·63-0·99]). All comparisons across the network were rated as low or very low confidence, except for direct comparisons between a low FODMAP diet or a starch-reduced and sucrose-reduced diet and habitual diet, both of which were rated as moderate confidence.

INTERPRETATION

In terms of dietary interventions for IBS, the most evidence exists for a low FODMAP diet, but other promising therapies are emerging and should be the subject of further study.

FUNDING

None.

Unravelling behavioural contributions to IBS risk: evidence from univariate and multivariate Mendelian randomisation

Background

While numerous studies have investigated the link between behavioural factors and irritable bowel syndrome (IBS), the causal relationships remain unresolved. This study applied Mendelian randomisation (MR) analysis to assess the causal impact of specific behavioural factors on IBS risk.

Methods

Bidirectional Mendelian randomisation analysis was employed to evaluate the causal relationships between behavioural factors and IBS risk. A genome-wide significance threshold (P < 5e-6) was applied to identify associations between genetic variants and behaviour-related traits, ensuring robust selection of instrumental variables for evaluating potential causal effects. Genetic correlations with IBS were sourced from extensive genome-wide association studies (GWASs). Various statistical methods were applied to estimate the causal effects.

Results

This study employed both univariate and multivariate Mendelian randomisation analyses to investigate the causal relationships between specific behavioural factors and the risk of irritable bowel syndrome (IBS). The results indicated that body mass index (BMI) (odds ratio (OR) = 1.074; 95% confidence interval (CI) = 1.025-1.125, P = 0.031), insomnia (OR = 1.986; 95% CI = 1.652-2.389, P < 0.001), duration of mobile phone use (OR = 1.120; 95% CI = 1.018-1.232, P = 0.021), and weekly mobile phone usage time in the past three months (OR = 1.148; 95% CI = 1.016-1.298, P = 0.021,) were associated with an increased risk of IBS. In contrast, usual walking speed (OR = 0.756; 95% CI = 0.621-0.920, P < 0.001), non-smoking status (OR = 0.779; 95% CI = 0.645-0.941, P < 0.001), and weekly alcohol consumption (OR = 0.862; 95% CI = 0.743-0.999, P = 0.015) were associated with a reduced risk of IBS. Furthermore, in the multivariate Mendelian randomisation analysis, no statistically significant causal associations were found for BMI, usual walking pace, length of mobile phone use, and smoking status. Weekly mobile phone usage time in the past three months (OR = 1.439; 95% CI = 1.126-1.840, P = 0.0037,) and insomnia (OR = 1.468; 95% CI = 1.076-2.003, P = 0.0156) were identified as risk factors, while weekly alcohol intake (OR = 0.813; 95% CI = 0.677-0.975, P = 0.0257) acted as a protective factor.

Conclusions

This study identified BMI, insomnia, duration of mobile phone use, and weekly mobile phone usage time in the past three months as risk factors for IBS. In contrast, weekly alcohol consumption, usual walking pace, and non-smoking status were observed as protective factors. Additionally, in multivariable analysis, weekly mobile phone use, insomnia, and weekly alcohol consumption showed a direct influence on IBS risk when considered simultaneously.

Development and validation of a risk prediction tool for the diagnosis of inflammatory bowel disease in patients presenting in primary care with abdominal symptoms

INTRODUCTION

Patients with inflammatory bowel disease (IBD) may experience delays in their diagnosis. This study aimed to develop and validate a risk prediction tool for IBD.

METHODS

A retrospective cohort study was conducted using primary care data from 2010 to 2019, including symptomatic patients aged ≥18. UK-based primary care databases linked to hospital records were utilized for model development and validation. Cox proportional hazards models were used to derive risk equations for IBD, ulcerative colitis (UC), and Crohn's disease (CD) in men and women. Candidate predictors included demographics, comorbidities, symptoms, extraintestinal manifestations, and laboratory results. Model performance was evaluated using measures of fit, discrimination, and calibration at 1, 2, 3, and 5 years after symptom onset.

RESULTS

In total, 2 054 530 patients were included in the derivation cohort and 673 320 in the validation cohort. In the derivation cohort, 0.7% were diagnosed with IBD (66.3% UC and 33.7% CD). Predictors in the final IBD model included age, smoking, body mass index, gastrointestinal symptoms, extraintestinal manifestations, comorbidities, family history of IBD, and laboratory investigations. The model demonstrated good discrimination and calibration; C-statistic 0.78 (95% confidence interval [CI], 0.77-0.79) in men and 0.78 (95% CI, 0.77-0.79) in women. In the validation cohort, the model tended to slightly overestimate IBD risk at higher risk thresholds.

CONCLUSIONS

A risk model using patient demographics, symptoms, and laboratory results accurately predicted IBD, UC, and CD at 1, 2, 3, and 5 years after symptom onset, potentially aiding in prioritizing patients for a referral or fecal calprotectin testing in primary care.

Developing a core outcome set for nutrition care in adult outpatients with irritable bowel syndrome (COS-RD-IBS study)

BACKGROUND AND AIMS

Irritable bowel syndrome (IBS) is a frequent disorder thought to be caused by a disturbance of the gut-brain axis. Nutrition interventions are an essential pillar of its treatment. However, there is no consensus on which outcomes should be applied to assess the effectiveness of nutrition care in IBS. Standardized outcome sets, or "core outcome sets" (COS), have been proposed to harmonize outcomes in clinical research and practice. This project aims to develop a COS for dietitian-provided nutrition care in adults with IBS or food intolerances with intestinal symptoms, to be implemented in routine outpatient practice.

METHODS

A comprehensive outcomes list was developed based on quantitative and qualitative studies, COS and guidelines on IBS, and important outcomes named by participants. Health service users, dietitians, gastroenterologists, and health care decision makers rated the outcomes in two Delphi survey rounds on their importance and ranked them in a third round. Data was analyzed by panel to account for the different views and sample sizes.

RESULTS

A total of 192 participants registered for the Delphi process. The following 14 outcomes reached consensus in all panels after two rounds: perception of symptom triggering foods/nutrients, intake of trigger foods/nutrients, practicability of diet, adherence, digestive symptoms overall, abdominal pain, abdominal bloating, stool consistency, stool frequency, physical functioning related QoL, nutrition related QoL, social functioning related QoL, empowerment of self-care.

CONCLUSIONS

The Delphi process yielded in a 14 outcomes COS, which exceeds what is typically considered feasible in routine nutrition care. Further work is needed to refine the COS and to identify standardized measurement tools for each outcome.

Diet therapy (The 8×5 Diet) for adults living with bile acid diarrhoea: protocol for a feasibility randomised controlled trial

INTRODUCTION

A national research priority for people living with bile acid diarrhoea (BAD) is effective treatment options to improve their quality of life. This study aims to evaluate the feasibility of conducting a randomised controlled trial (RCT) of a novel healthy dietary pattern (The 8×5 Diet) to inform a future, larger trial.

METHODS AND ANALYSIS

We plan to enrol 76 UK adults living with BAD and ongoing diarrhoea using self-selection sampling and digital technologies. Eligible participants will be assigned to groups using permuted block randomisation using 1:1 allocation to receive either 8 weeks of usual care or The 8×5 Diet using one-to-one, dietitian counselling via a video-conferencing platform and developed digital resources. Randomisation, consent, recruitment, retention and acceptability will be evaluated using data from the RCT and post-trial interviews conducted with those in the intervention group. Secondary outcome exploratory assessment will include health-related quality of life, symptom relief, diarrhoea, diet quality, nutrient intakes and diet satisfaction.

ETHICS AND DISSEMINATION

Ethical approval was granted by the University of Manchester Research Ethics Committee (2024-19094-33261; V1.7, last updated: 24/02/2025).Findings will be disseminated through peer-reviewed publication, conference presentation and social media.

TRIAL REGISTRATION NUMBER

NCT06259396.

Is there a sex difference in response to FODMAP diet group education for IBS? A clinical practice service evaluation

Background: While the low fermentable oligosaccharides, disaccharides, monosaccharides and polyols diet, low FODMAP diet (LFD) has demonstrated effectiveness in managing irritable bowel syndrome (IBS) symptoms, little is known about sex-specific responses to this dietary intervention. Aim: This study evaluates the role of sex differences in symptom improvement following a dietitian-led, group education session on the LFD for IBS patients. Methods: A total of 305 patients, including 249 with a diagnosis of IBS and 56 classified as having suspected IBS, were enrolled in this study (79.7% female). Patients attended two group education sessions on the LFD. Primary outcomes were measured using the IBS Symptom Severity Score (IBS-SSS) and the Global Symptom Question (GSQ). Secondary outcomes included stool frequency, stool consistency and individual symptoms assessed by the Gastrointestinal Symptom Rating Scale. Statistical analyses were performed to compare baseline and follow-up data within and between sexes. Results: Both male and female patients experienced significant reductions in IBS-SSS scores and improvements in GSQ satisfactory relief, stool frequency, stool consistency and individual gastrointestinal (GI) symptoms following the LFD (p < 0.05). There were no significant between-sex differences in the extent of symptom relief (p > 0.05). Conclusion: The study found no significant sex-based differences in symptom reduction or GI relief following the intervention. These findings suggest that, despite differing symptom profiles and IBS prevalence, both male and female patients achieve similar relief with the LFD group education.

The association between the Mediterranean Diet and the prime diet quality score and new-diagnosed irritable bowel syndrome: a matched case-control study

Background

Irritable bowel syndrome (IBS) is a prevalent functional gastrointestinal disorder with multifactorial etiology. Dietary patterns, including the Mediterranean Diet (Med-Diet) and the Prime Diet Quality Score (PDQS), may play a role in IBS risk. This study examined the association between adherence to the Med-Diet and PDQS and new-diagnosed IBS in an Iranian population.

Methods

A matched case-control study was conducted on 170 newly diagnosed IBS patients and 340 age- and sex-matched controls recruited from outpatient clinics in Zanjan, Iran. Dietary intake was assessed using a semiquantitative food frequency questionnaire. The Med-Diet score and PDQS were calculated, with higher scores indicating better diet quality. Conditional logistic regression was used to determine the odds of IBS across quartiles of Med-Diet and PDQS, adjusting for sociodemographic and clinical factors.

Results

Higher adherence to the Med-Diet was associated with 51% lower odds of IBS (OR: 0.49; 95% CI: 0.30-0.73, P < 0.001) in the highest quartile compared to the lowest. Similarly, participants in the highest PDQS quartile showed a significantly 59% lower odds of IBS (OR: 0.41; 95% CI: 0.26-0.51, P < 0.001) compared to the lowest quartile. Both associations remained significant after adjusting for potential confounders, including total energy intake. These findings highlight the potential clinical relevance of dietary quality in IBS prevention.

Conclusion

Higher adherence to the Med-Diet and a higher PDQS were both inversely associated with IBS risk. Specifically, individuals with higher Med-Diet scores and higher PDQS scores had a lower risk of developing IBS compared to those with lower adherence or scores. These findings suggest a potential role of these dietary patterns in modulating IBS risk, although causal relationships cannot be established from this study.

Functional Foods and Nutraceuticals in Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a common disorder of gut-brain interaction, with a multifactorial pathophysiology involving gut-brain axis dysregulation, visceral hypersensitivity, microbiota imbalance, and immune dysfunction. Traditional IBS management emphasizes dietary modifications and pharmacologic therapies. However, increasing attention has been directed toward functional foods, nutraceuticals, and herbal remedies due to their potential to target IBS pathophysiological mechanisms with favorable safety profiles. This clinical review explores the role of these adjunctive therapies, evaluating evidence from preclinical and clinical studies. Functional foods such as kiwifruit, prunes, and rye bread demonstrate benefits in bowel habit regulation through fiber content and microbiota modulation. Nutraceuticals like peppermint oil, palmitoylethanolamide, and herbal mixtures exhibit anti-inflammatory, antispasmodic, and analgesic effects. Prebiotics provide substrate-driven microbiota changes, although dosage is key, as given their fermentative properties, when used at high dosages, they can exacerbate symptoms in some individuals. Probiotics and postbiotics offer microbiota-based interventions with promising symptom relief in IBS subtypes, although factors for personalized treatment still need to be further elucidated. These strategies highlight a paradigm shift in IBS management, integrating diet-based therapies with evolving nutraceutical options to improve patient outcomes. Despite promising findings, challenges in standardizing definitions, mechanisms, and safety profiles still remain. Rigorous, large-scale trials to validate the therapeutic potential of these interventions are needed, to enhance the benefits of these compounds with an individualized treatment approach.

Specialty laboratory testing for chronic abdominal pain in irritable bowel syndrome

BACKGROUND

Irritable bowel syndrome (IBS) is a common gastrointestinal disorder seen by both primary care providers (PCPs) and gastroenterologists, and further diagnostic testing is generally discouraged unless red-flag symptoms are present.

AIMS

Examine if advanced serologic testing for chronic abdominal pain in IBS patients followed society-specific guidelines and evaluate the diagnostic accuracy of these tests.

METHODS

The study involved a retrospective cross-sectional analysis of adults aged 18 and older who were seen at our institution between 2013 and 2018. Tests included: C1 esterase inhibitor, MEFV gene, urine porphobilinogen, anti-dsDNA, and heavy metal screening. Patients with preexisting rheumatological conditions or diagnoses such as hereditary angioedema, porphyria, familial Mediterranean fever, or lead poisoning were excluded. An appropriateness scale based on disease-specific guidelines was used to evaluate test suitability.

RESULTS

Among 26,732 IBS patients, 143 underwent advanced laboratory testing, with 85.3% ordered by gastroenterologists. Only 12.5% of tests adhered to society-specific guidelines, and the positive test rate was 2.1%. The total cost of testing was $46,542, with $39,007 spent on tests deemed inappropriate.

CONCLUSIONS

The findings emphasize the effectiveness and importance of adhering to Rome IV criteria, as advanced testing often fails to improve diagnostic accuracy and increases unnecessary healthcare costs.

Intestinal Permeability in Disorders of Gut-Brain Interaction: From Bench to Bedside

Intestinal barrier function lies at a critical interface of a range of peripheral and central processes that influence disorders of gut-brain interactions (DGBI). Although rigorously tested, the role of barrier dysfunction in driving clinical phenotype of DGBI remains to be fully elucidated. In vitro, in vivo, and ex vivo strategies can test various aspects of the broader permeability and barrier mechanisms in the gut. Luminal mediators of host, bacterial, and dietary origin can influence the barrier function and a disrupted barrier can also influence the luminal milieu. Critical to our understanding is how barrier dysfunction is influenced by stress and other comorbidities that associate with DGBI and the crosstalk between barrier and neural, hormonal, and immune responses. Additionally, the microbiome's significant role in the communication between the brain and gut has led to the integrative model of a microbiome gut-brain axis with reciprocal interactions between brain networks and networks composed of multiple cells in the gut, including immune cells, enterochromaffin cells, gut microbiota and the derived luminal mediators. This review highlights the techniques for assessment of barrier function, appraises evidence for barrier dysfunction in DGBI including mechanistic studies in humans, as well as provides an overview of therapeutic strategies that can be used to directly or indirectly restore barrier function in DGBI patients.

Exploring Dietitians' Perspectives Toward Current Practices and Services in Relation to Irritable Bowel Syndrome Management in Clinical Settings Across the United Kingdom: A Qualitative Study

BACKGROUND

Irritable bowel syndrome (IBS) is a chronic and relapsing gastrointestinal condition that negatively impacts quality of life. Dietary triggers are common and dietary management is central to the IBS treatment pathway, and dietitians are the main education providers for patients.

OBJECTIVE

The aim of this study was to explore dietitians' perspectives on current practices and services in relation to IBS management in clinical settings across the United Kingdom.

DESIGN

Qualitative semi-structured interviews were undertaken from May to October 2021 via videoconferencing software. Eligible participants were dietitians specializing in gastroenterology and working in National Health Service (NHS) Trusts in the United Kingdom. Interviews were audio recorded and transcribed following intelligent transcription. Template analysis guided by naïve realism and its underlying epistemological assumptions was used.

PARTICIPANTS/SETTING

Dietitians (N = 13) working in various NHS Trusts across the United Kingdom with at least 1 year of clinical experience in IBS management were included.

QUALITATIVE DATA ANALYSIS

Template analysis, a form of thematic analysis with hierarchical coding, was used to explore dietitians' perspectives of IBS practices.

RESULTS

Participating dietitians were mostly female (92.3%), of White race (84.6%), working in various NHS Trusts across the United Kingdom, and had more than 5 years of clinical experience (69.2%). The following 3 main themes emerged: 1) dietetics services as part of IBS referral pathways; 2) practices in relation to dietetics services; and 3) patients' expectations and feelings. Each main theme had subthemes to facilitate the description and interpretation of data. The increasing number of IBS referrals to dietitians and the need for accurate and timely IBS diagnosis and specialist dietitians were reported, along with the use of digital innovation to facilitate practice and access to dietetic care. The use of internet as a source of (mis)information by patients and the limited time available for educating patients were identified as potential barriers to dietetic practice. Dietitians follow a patient-centered approach to dietary counseling and recognize the negative implications of perceived IBS-related stigma by patients on their feelings and treatment expectations.

CONCLUSIONS

The study identified areas and practices that can facilitate access to dietetic services and patient-centered care in IBS management, as outlined in UK-based guidelines.

Colonoscopic administration of probiotics to treat irritable bowel syndrome with predominant diarrhea: a randomized placebo-controlled clinical trial

BACKGROUND

To investigate the effects of colonoscopic administration of probiotics on patients with irritable bowel syndrome with predominant diarrhea (IBS-D) by a single-center, randomized-controlled trial.

METHODS

Consecutive outpatients at the First Affiliated Hospital of Fujian Medical University who met the Rome IV diagnostic criteria for IBS-D (n = 22) and healthy subjects (n = 10) from January 2017 to January 2018 were enrolled. IBS-D patients were randomly divided into either the probiotics or the placebo group. During the colonoscopy examination, a suspension of live combined Bifidobacterium with Lactobacillus tablets and normal saline was sprayed into the right colon of patients in the probiotics and the placebo group, respectively. All subjects' clinical data and stool samples were collected before, 2 weeks and 4 weeks after colonoscopic treatment.

RESULTS

Twenty-nine subjects completed the follow-up. A significant difference was found in the frequency of defecation at 2 weeks, and the abdominal Visual Analog Score and Bristol stool scale at 4 weeks after probiotics treatment. The gastrointestinal symptom rating scale and IBS severity score decreased significantly and the IBS Quality of Life Instrument score increased 2 weeks after probiotics treatment (p < 0.05). The comprehensive therapeutic index was 70.0% and 44.4% in the probiotics group and the placebo group, respectively. The gut microbiota diversity was not significantly different at 2 and 4 weeks after treatment among the groups. Ratio of Firmicutes to Bacteroidetes decreased in the probiotics group.

CONCLUSIONS

The symptoms of IBS-D could be improved by probiotics administration via colonoscopy. The study was registered on chictr.org.cn (ChiCTR-IPR-17010411).

Clinical Trial: Study to Investigate the Efficacy and Safety of the Alpha-2-Delta Ligand PD-217,014 in Patients With Irritable Bowel Syndrome

INTRODUCTION

Despite the emergence of drugs to treat irritable bowel syndrome (IBS), improving abdominal pain can still be challenging. α2δ ligands, such as gabapentin and pregabalin, are sometimes used off-label to tackle this problem. However, evidence for efficacy is limited, and no large-scale studies have been published.

AIM

To study the efficacy of the α2δ ligand PD-217,014 in IBS.

METHODS

This multi-centre, double-blind, randomised, placebo-controlled, parallel group study randomised participants with Rome II-defined IBS to 150 or 300 mg b.d. of PD-217,014 or placebo b.d. for 4 weeks. The primary efficacy endpoint was responder, defined as having adequate relief of abdominal pain/discomfort for ≥ 50% of the active treatment period. Key secondary endpoints were change from baseline in abdominal pain, bloating, stool frequency/consistency, and global assessment of IBS symptoms.

RESULTS

We randomised 330 participants [aged 19-73 years; 209 (65%) female] satisfying Rome II criteria, 322 (98%) were treated, and of whom 271 (84%) completed the study. In this study, 321 satisfied Rome IV criteria. Neither dose of PD-217,014 improved the percentage of participants reporting adequate relief of abdominal pain/discomfort compared with placebo, either using the Rome II-defined total cohort or Rome II and IV IBS bowel habit sub-types. There were similar observations for secondary endpoints, and no association between abdominal pain or anxiety levels at baseline with participant improvement. PD-217,014 was generally well tolerated.

CONCLUSION

This first large, dose-ranging trial examining the efficacy of PD-217,014 showed no significant efficacy in participants with IBS or bowel habit sub-types, irrespective of their pain and anxiety levels.

Complex Probiotics Ameliorate Fecal Microbiota Transplantation-Induced IBS in Mice via Gut Microbiota and Metabolite Modulation

Background/Objectives: Irritable bowel syndrome (IBS) is a highly prevalent functional gastrointestinal disorder. Emerging evidence implicates gut microbiota dysbiosis in IBS pathogenesis, and probiotic interventions targeting microbial modulation hold therapeutic promise. Methods: this study used fecal microbiota transplantation to establish a mouse model of IBS before evaluating the effects of the complex probiotic by using metagenomics and targeted metabolomics to explore the potential mechanism. Results: After 14 days, the probiotic relieved constipation, reduced inflammation and intestinal permeability, lowered 5-HT levels and increased serotonin transporter (SERT) expression in tissues. Metagenomic analysis showed a reduced inflammation-related species abundance. It also decreased fecal butyric acid, acetic acid and tryptophan levels in IBS mice. Conclusions: The probiotic complex effectively alleviated IBS symptoms in mice by modulating gut microbiota and fecal metabolites, providing insights for future IBS research and treatment.

Comparison of Digitally Delivered Gut-Directed Hypnotherapy Program With an Active Control for Irritable Bowel Syndrome

INTRODUCTION

Gut-directed hypnotherapy (GDH) treats irritable bowel syndrome (IBS), but its accessibility is limited. This problem may be overcome by digital delivery. The aim of this study was to perform a randomized control trial comparing the efficacy of a digitally delivered program with and without GDH in IBS.

METHODS

Adults with IBS were randomized to a 42-session daily digital program with the GDH Program (Nerva) or without (Active Control). Questionnaires were completed to assess gastrointestinal symptoms through IBS Symptom Severity Scale (IBS-SSS), quality of life, and psychological symptoms (Depression Anxiety and Stress Scale-21) at regular intervals during the program and 6 months following the conclusion on the intervention. The primary end point was the proportion of participants with ≥50-point decrease in IBS-SSS between the interventions at the end of the program.

RESULTS

Of 240/244 randomized participants, 121 received GDH Program-the median age 38 (range 20-65) years, 90% female, IBS-SSS 321 (interquartile range 273-367)-and 119 Active Control-36 (21-65), 91% female, IBS-SSS 303 (255-360). At program completion, 81% met the primary end point with GDH Program vs 63% Active Control ( P = 0.002). IBS-SSS was median 208 (interquartile range 154-265) with GDH and 244 (190-308) with control ( P = 0.004), 30% reduction in pain was reported by 71% compared with 35% ( P < 0.001), and IBS quality of life improved by 14 (6-25) compared with 7 (1-15), respectively ( P < 0.001). Psychological status improved similarly in both groups.

DISCUSSION

A digitally delivered GDH Program provided to patients with IBS was superior to the active control, with greater improvement in both gastrointestinal symptoms and quality of life and provides an equitable alternative to face-to-face behavioral strategies.

An 8-Week Course of Bifidobacterium longum 35624® Is Associated with a Reduction in the Symptoms of Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is one of the disorders most frequently diagnosed by gastroenterologists. Probiotics are promising tools for the management of IBS. The objective of the present study was to evaluate the effectiveness and tolerability of a probiotic (Bifidobacterium longum 35624®) in adults (aged 18 or over) with IBS (as defined by the Rome IV criteria). In an open-label, observational, post-market study conducted in Germany, adults with IBS and a prior recommendation for the intake of B. longum 35624® were recruited by family physicians. During the 8-week course of treatment, the study participants filled out a weekly questionnaire that enabled calculation of a total IBS symptom score (TISS, the sum of abdominal pain, bloating, passage of gas, constipation, and diarrhea individual symptom scores) and the well-known IBS severity scoring system (IBS-SSS) score. Thirty-seven patients were included. The course of B. longum 35624® was associated with a significant reduction (43.4%) in the TISS vs. baseline. The mean individual symptom grades for passage of gas and bloating fell significantly from "moderate" at baseline to "very mild to mild" after 8 weeks of treatment, whereas those for abdominal pain and diarrhea fell significantly from "mild to moderate" to "very mild to mild." Over 60% of the participants achieved clinically meaningful reductions in the TISS (> 30%) and the IBS-SSS score (> 50 points). The effectiveness of B. longum 35624® was rated as "good to satisfactory" by study participants and the investigating physicians. One mild adverse event (nausea) was potentially linked to the study treatment. We conclude that an 8-week course of B. longum 35624® was associated with significant, clinically meaningful symptom relief in a typical population of adult patients with IBS.

Patients with functional gastrointestinal disorders spend less time in tertiary care when managed by a single clinician: results of a multicentre audit in South Australia

BACKGROUND AND AIMS

Functional gastrointestinal disorders (FGIDs) impact quality of life and represent a significant burden on healthcare services. Guidelines recommend an early, positive diagnosis to reduce harmful over-investigation in FGID patients. The aim of this multicentre study was to evaluate FGID management against current guidelines.

METHODS

A multicentre, retrospective evaluation of patients with a primary diagnosis of FGID across two tertiary gastroenterology services over a 12-month period was performed. Time to diagnosis of a FGID, number of outpatient encounters, number and type of investigations performed and time to discharge from the outpatient service were assessed. Whether care was delivered by single or multiple clinicians was recorded. Statistical analysis was performed using Student's t test, logistic regression analysis and Kaplan-Meir curves.

RESULTS

Between June 2021 and June 2022, 275 individual patients were reviewed primarily for FGID. Median time to FGID diagnosis was 70 days (interquartile range (IQR): 0-175), over a median of four outpatient encounters (IQR: 3-6), with an overall time in service of 182 days (IQR: 105-344). When care was delivered by a single rather than multiple clinicians, patients were more likely to receive a FGID diagnosis early (hazard ratio (HR): 1.6, 95% confidence interval (CI): 1.25-2.04, P < 0.0001), be discharged sooner (HR: 1.83, 95% CI: 1.44-2.33, P < 0.0001), with a trend towards less harmful investigations (odds ratio: 1.79, 95% CI: 0.96-3.58, P = 0.08).

CONCLUSIONS

Consistent delivery of clinical care reduces healthcare utilisation in the management of FGIDs. Further studies are needed to identify optimal care models for managing outpatients with FGIDs.

Improving Irritable Bowel Syndrome (IBS) Symptoms and Quality of Life with Quebracho and Chestnut Tannin-Based Supplementation: A Single-Centre, Randomised, Double-Blind, Placebo-Controlled Clinical Trial

Background/Objectives: Irritable Bowel Syndrome (IBS) is a disorder of the gut-brain axis for which the gastroenterologist is most often consulted. Gastrointestinal symptoms and decreased quality of life lead to a considerable burden of disease. The exact causes of IBS are not well understood, and no standard therapy has been established. The primary outcome of the study focused on the improvements of the IBS symptoms assessed through the validated questionnaire IBS-Severity Scoring System (IBS-SSS). Similarly, secondary outcomes geared towards the improvement of the quality of life (IBS-Quality of Life (IBS-QoL) and the Gastrointestinal Quality of Life Index (GIQLI)) and specific IBS symptoms (bloating, abdominal distension, feeling of heaviness, abdominal pain, and flatulence), were assessed through self-administered questionnaires. Intestinal habits (consistency and frequency of depositions) through subject stratification into diarrhoea (IBS-D), constipation (IBS-C), mixed type (IBS-M), as well as the treatment tolerability were also evaluated. Methods: A randomised, placebo-controlled, double-blind, clinical trial was conducted on 156 enrolled IBS patients (79 female and 77 male), aged 18-70 years, randomised (1:1 allocation ratio) to receive either two capsules per day of the food supplement (containing 480 mg of a complex of tannin extracts) or a placebo for 56 days. Linear random intercept mixed models (LMM) were used to analyse all experimental variables Results: Supplementation resulted in a significant improvement (p < 0.05) in the primary outcome IBSS score, with respect to the placebo group, changing the IBS condition going from mild (242.3 ± 89.8) to moderate (148.1 ± 60.6). Similarly, all indicators concerning quality of life, and specific intestinal symptoms resulted in a significant improvement (p < 0.05). Furthermore, the tannin-based treatment showed the ability to modulate the response to different symptomatology such as diarrhoea and constipation, without side effects being reported. Conclusions: The use of a supplement based on chestnut and quebracho tannins presents great application potential in the management of IBS-related disorders, with the peculiarity of resolving opposite symptoms, such as diarrhoea and constipation, indiscriminately.

Efficacy of Amitriptyline in Irritable Bowel Syndrome: A Systematic Review and Meta-analysis

Background/Aims

Amitriptyline is prescribed off-label for irritable bowel syndrome (IBS). We conducted a meta-analysis to assess its efficacy.

Methods

A systematic literature review was conducted until November 10, 2023, using MEDLINE, Embase, Cochrane Library, and Web of Science to study the efficacy of amitriptyline in patients with IBS. We included all randomized controlled trials that compared amitriptyline to placebo. Revised Cochrane risk-of-bias tool was used to assess the quality of studies. Meta-analyses were performed using a bivariate random-effects model. Statistical analyses were performed using R Software 4.2.3 and heterogeneity was assessed with I2 statistics.

Results

Seven trials were included with 796 patients (61% female). Amitriptyline was associated with better treatment response (OR, 5.30; 95% CI, 2.47 to 11.39; P < 0.001), reduced Irritable Bowel Syndrome Symptom Severity Scores (MD, -50.72; 95% CI, -94.23 to -7.20; P = 0.020) and improved diarrhea (OR, 10.55; 95% CI, 2.90 to 38.41; P < 0.001). No significant difference between the 2 groups regarding the adverse effects was observed. Three trials showed an overall low risk of bias, 2 trials showed an overall high risk of bias due to randomization and missing data, and 2 trials had some concerns regarding missing data.

Conclusions

Amitriptyline was found to be well-tolerated and effective in treating IBS compared to placebo. These findings support the use of amitriptyline for the management of IBS, particularly among patients with the IBS diarrhea subtype. Future research should focus on the dose-dependent effects of amitriptyline in IBS to better guide clinicians in personalized titration regimens.

Development and validation of a novel 7α-hydroxy-4-cholesten-3-one (C4) liquid chromatography tandem mass spectrometry method and its utility to assess pre-analytical stability

OBJECTIVES

7α-Hydroxy-4-cholesten-3-one (C4) is the common intermediary of both primary bile acids. C4 is recommended by the British Society of Gastroenterology for the investigation of bile acid diarrhoea (BAD) in patients with chronic diarrhoea. This project aimed to develop and validate an assay to quantitate C4 in serum and assess the stability of C4 in unseparated blood.

METHODS

Accuracy was underpinned by calibrating to quantitative nuclear magnetic resonance analysis. C4 was analysed in a 96-well plate format with a deuterated C4 internal standard and liquid-liquid extraction. Validation followed the 2018 Food and Drug Administration guidelines. To assess C4 stability, healthy volunteers (n=12) donated 8 fasted samples each. Samples were incubated at 20 °C for up to 72 h and retrieved, centrifuged, aliquoted and frozen for storage at different time points prior to C4 analysis.

RESULTS

The C4 method demonstrated excellent analytical performance and passed all validation criteria. The method was found to be accurate, precise, free from matrix effects and interference. After 72 h of delayed sample separation, C4 concentration gradually declined by up to 14 % from baseline. However, the change was not significant for up to 12 h.

CONCLUSIONS

We present a robust method of analysing serum C4, offering a convenient alternative to 75SeHCAT for BAD investigation. C4 was found to decline in unseparated blood over time; however, after 12 h the mean change was <5 % from baseline. Our results suggest C4 is suitable for collection from both primary and secondary care prior to gastroenterology referral.

An evidence-based update on the diagnosis and management of irritable bowel syndrome

INTRODUCTION

Irritable bowel syndrome (IBS) is a disorder of gut-brain interaction affecting 5% of the population. The cardinal symptoms are abdominal pain and altered stool form or frequency.

AREAS COVERED

Diagnosis and management of IBS. We searched the literature for diagnostic accuracy studies, randomized controlled trials, and meta-analyses. A positive diagnosis of IBS, alongside testing to exclude celiac disease, is recommended. Exhaustive investigation has a low yield. Patients should be offered traditional dietary advice. If response is incomplete, specialist dietetic guidance should be considered. Probiotics may be beneficial, but quality of evidence is poor. First-line treatment of constipation is with laxatives, with secretagogues used where these are ineffective. Anti-diarrheal drugs should be used first-line for diarrhea, with second-line drugs including 5-hydroxytryptamine-3 antagonists, eluxadoline, or rifaximin, where available. First-line treatment of abdominal pain should be with antispasmodics, with gut-brain neuromodulators prescribed second-line. Low-dose tricyclic antidepressants, such as amitriptyline, are preferred. Brain-gut behavioral therapies are effective and have evidence for efficacy in patients refractory to standard therapies.

EXPERT OPINION

Despite substantial advances, there remains scope for improvement in terms of both the diagnosis and management of IBS. Reinforcement of positive diagnostic strategies for the condition and novel treatment paradigms are required.

Non-Celiac Gluten/Wheat Sensitivity-State of the Art: A Five-Year Narrative Review

Background: Non-celiac gluten/wheat sensitivity (NCGWS) is a syndrome for which pathogenesis and management remain debated. It is described as a condition characterized by gastrointestinal and extra-intestinal symptoms rapidly occurring after gluten ingestion in subjects who have had celiac disease or wheat allergy excluded. To date, the diagnosis of NCGWS is challenging as no universally recognized biomarkers have been yet identified, nor has a predisposing genetic profile been described. However, the research is moving fast, and new data regarding pathogenic pathways, patients' classification, potential candidate biomarkers, and dietary interventions are emerging. Methods: This literature review aims to address the state of the art and summarize the latest updates in this field from 2019 to date. Results and Conclusions: Clinical studies regarding NCGWS in the last five years are reported to shed light on this complex condition and to guide specialists towards a more in-depth, prompt, and objective diagnosis.

Efficacy of fermented foods in irritable bowel syndrome: a systematic review and meta-analysis of randomized controlled trials

Objective

Fermented foods (FFs) may theoretically benefit irritable bowel syndrome (IBS) symptoms, but the role of FFs for IBS patients in the real world is inconsistent and has not been systematically assessed. We performed a systematic review and meta-analysis to examine this issue.

Methods

PubMed, MEDLINE, Embase and Cochrane Library databases were searched up to August 2024. Randomized controlled trials (RCTs) investigating the efficacy of FFs in IBS were eligible for the analysis. Two authors independently screened studies and extracted data. Data were pooled using relative risk (RR) of dichotomous data and standardized mean difference (SMD) for continuous data.

Results

A total of 16 RCTs with 1,264 IBS patients were included. There were 12 RCTs involving 975 patients providing primary outcomes which was defined as symptom relief. The proportion of symptom relief was associated with the administration of FFs (RR 1.22, 95% CI 1.04-1.42, p = 0.01, I 2 = 0%). For secondary outcomes, FFs also exerted a beneficial effect on global symptoms scores (SMD = -0.15; 95% CI -0.29 to -0.02, p = 0.02, I 2 = 46%), but no significant improvement on abdominal pain scores and bloating scores. Subgroup analysis showed that fermented milk had a beneficial effect on symptom relief (RR 1.19, 95% CI 1.01 to 1.39, p = 0.04, I 2 = 0%).

Conclusion

Fermented foods, especially fermented milk with probiotics properties, appear to be efficacious in irritable bowel syndrome. However, given the limitations of current evidence, this conclusion should be interpreted with caution.

Systematic Review Registration

This study was registered on the International Prospective Register of Systematic Reviews (PROSPERO) as CRD42024576608.

Neurogastroenterology and motility disorders in patients with cirrhosis

Neurogastroenterology and motility disorders are complex gastrointestinal conditions that are prevalent worldwide, particularly affecting women and younger individuals. These conditions significantly impact the quality of life of people suffering from them. There is increasing evidence linking these disorders to cirrhosis, with a higher prevalence compared to the general population. However, the link between neurogastroenterology and motility disorders and cirrhosis remains unclear due to undefined mechanisms. In addition, managing these conditions in cirrhosis is often limited by the adverse effects of drugs commonly used for these disorders, presenting a significant clinical challenge in the routine management of patients with cirrhosis. This review delves into this connection, exploring potential pathophysiological links and clinical interventions between neurogastroenterology disorders and cirrhosis.

Validating Simple Modifications to the Rome IV Criteria for the Diagnosis of Irritable Bowel Syndrome in Secondary Care

BACKGROUND

The Rome IV criteria for irritable bowel syndrome (IBS) may be too restrictive for clinical practice and research.

AIMS

To validate the Rome IV criteria and study the diagnostic performance of simple modifications to them.

METHODS

We collected symptom data from consecutive adults with suspected IBS seen in a single clinic. We used a reference standard to confirm IBS (presence of lower abdominal pain associated with altered stool form or frequency; no evidence of organic gastrointestinal disease after limited investigation). We applied Rome IV criteria, but also two modifications. First, we re-incorporated abdominal discomfort but kept symptom frequency required for both abdominal pain and discomfort to at least 1 day per week. Second, we included only abdominal pain but relaxed symptom frequency back to 3 days per month. We calculated sensitivity, specificity and positive and negative likelihood ratios (LRs), with 95% confidence intervals (CIs), for each diagnostic criterion.

RESULTS

We recruited 170 patients (76.5% female, mean age 37.9 years). Sensitivity and specificity of the Rome IV criteria were 82.1% and 85.1%, respectively; positive and negative LRs were 5.51 (95% CI 2.95-11.3) and 0.21 (95% CI 0.14-0.31), respectively. Modifying the criteria by relaxing the frequency of abdominal pain to 3 days per month led to the best performance [sensitivity 90.2%, specificity 85.1%, positive LR 6.06 (95% CI 3.25-12.2), and negative LR 0.11 (95% CI 0.07-0.19)].

CONCLUSIONS

The Rome IV criteria performed well in diagnosing IBS. A simple modification relaxing the required frequency of abdominal pain improved their performance.

Non-pharmaceutical treatments for irritable bowel syndrome

Irritable bowel syndrome (IBS) is a chronic disorder of gut-brain interaction that impacts a significant portion of the population and is associated with substantial morbidity, reduced quality of life, and economic impact globally. The pathophysiology of IBS is complex and incompletely understood, and the heterogeneity of IBS is reflected in the variety of pharmaceutical and non-pharmaceutical therapies utilized for the management of IBS. Given limitations with pharmaceutical treatments, many patients with IBS seek non-pharmaceutical options. Several non-pharmaceutical treatments such as the low FODMAP diet and brain-gut behavior interventions such as gut directed hypnosis and cognitive behavioral therapy are now considered standard of care and are part of all major guidelines for the treatment of IBS. However, challenges with access to and optimal implementation of these therapies remain. This review focuses on the current evidence for common non-pharmaceutical treatments for IBS, including the latest advances in dietary and brain-gut behavioral care, in addition other complementary and integrative health practices and emerging therapies.

Microbiota modulation in disorders of gut-brain interaction

Disorders of gut-brain interaction (DGBI) are common chronic conditions characterized by persistent and recurring gastrointestinal symptoms triggered by several pathophysiological factors, including an altered gut microbiota. The most common DGBI are irritable bowel syndrome (IBS), functional constipation (FC) and functional dyspepsia (FD). Recently, a deep understanding of the role of the gut microbiota in these diseases was possible due to multi-omics methods capable to provide a comprehensive assessment. Most of the therapies recommended for these patients, can modulate the gut microbiota such as diet, prebiotics, probiotics and non-absorbable antibiotics, which were shown to be safe and effective. Since patients complain symptoms after food ingestion, diet represents the first line therapeutic approach. Avoiding dietary fat and fermentable oligosaccharides, disaccharides, monosaccharides, and polyols, and increasing the number of soluble fibers represent the therapeutic choices for FD, IBS and FC respectively. Probiotics, as a category, have been employed with good results in all the abovementioned DGBI. Rifaximin has been shown to be useful in the context of bowel related disorders, although a recent trial showed positive results for FD. Fecal microbiota transplantation has been tested for IBS and FC with promising results. In this review, we will briefly summarize the current understanding on dysbiosis and discuss microbiota modulation strategies to treat patients with DGBI.

Chronic Abdominal Pain in Patients with Inflammatory Bowel Disease in Remission: A Continuing Challenge for Clinicians

Inflammatory bowel disease (IBD) is a chronic condition that includes ulcerative colitis and Crohn's disease. It is characterized by a relapsing and remitting pattern that negatively impacts quality of life (QoL). Current goals of treatment involve symptomatic, biochemical, and endoscopic remission in a treat-to-target approach. Despite effective treatment and remission of IBD, many patients report frequent and isolated abdominal pain. A wide range of etiologies exist, including surgery-related, infections, pelvic conditions, immune-related, and systemic illnesses. Disorders of the gut-brain interaction (DGBI), frequently characterized by abdominal pain, are increasingly recognized in IBD patients, including those with quiescent disease. Various mechanisms are involved and numerous non-pharmacologic and pharmacologic therapies have been proposed. Hereby, we outline the pertinent findings of the literature on management of chronic abdominal pain, focusing on quiescent IBD.

Abdominal Pain in Inflammatory Bowel Disease-Epidemiology, Pathophysiology, and Management: A Narrative Review

Abdominal pain is a major symptom of inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis, and has a significant impact on patients' quality of life. Given the evolving understanding of IBD pathology and management strategies, there is an urgent need to review the recent research findings. In this review, we have analyzed the epidemiology, pathophysiology, and management of abdominal pain in IBD over the past decade. We draw on the current literature and highlight emerging trends, challenges, and advances in this field. By synthesizing key findings, this review provides insights into the complex interplay between abdominal pain, disease progression, and therapeutic interventions for IBD.

Comparison of 4-week versus 8-week dietitian-led FODMAP diet group education sessions in tertiary care clinical practice for irritable bowel syndrome: A service evaluation

BACKGROUND

The implementation of the fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) diet for irritable bowel syndrome (IBS) can be effectively delivered by dietitians in group settings. The initial FODMAP restriction phase is recommended to be followed for 4 weeks; however, limited efficacy data exist for 4-week FODMAP restriction in group education clinical practice.

METHODS

We aimed to compare 4-week versus 8-week FODMAP group treatment pathways on clinical outcomes using a prospective service evaluation design of IBS patients attending FODMAP restriction (baseline) and reintroduction (follow-up) group sessions (between 2015 and 2019). Clinical outcomes included global symptom question (GSQ) measuring satisfactory relief, gastrointestinal symptom rating scale (GSRS), stool frequency (SF), stool consistency using Bristol stool form scale (BSFS), diet acceptability, patient satisfaction with group sessions and dietary adherence. Logistic regression was used to test for differences in treatment effects when clinical outcomes were compared between groups.

RESULTS

Patients (n = 284) included were aged 18 to 86 years (mean ± SD [standard deviation], 44.6 ± 15.5), 80% female, and were split into 4-week (41%, 117/284) versus 8-week (59%, 167/284) pathways with no differences in baseline characteristics. Mean ± SD time gap between baseline and follow-up was 4.6 ± 0.9 weeks in the 4-week pathway and 9.6 ± 3.3 weeks in the 8-week pathway. When groups were compared at follow-up, no statistical differences were observed in any measures (GSQ, GSRS, SF, BSFS, dietary adherence, diet acceptability and patient satisfaction).

CONCLUSION

A 4-week dietitian-led group FODMAP treatment pathway is as clinically effective and maintains patient acceptability when compared to 8-weeks and should be considered as part of routine clinical practice.

Rome III and IV criteria are less discordant to diagnose irritable bowel syndrome in clinic patients than in community subjects

BACKGROUND

Though Rome IV criteria for irritable bowel syndrome (IBS) are less sensitive; they select Rome III patients with greater severity and consultation behavior. Since severity of IBS may determine consultation behavior, we compared Rome III and IV criteria in clinic patients and compared with earlier published data from Indian community hypothesizing that the diagnostic discordance between these criteria would be less in clinic than in community.

METHODS

Tertiary clinic patients were screened for IBS using Hindi translated-validated Rome III and IV questionnaires; IBS symptom severity scores (IBS-SSS) was also assessed. Diagnostic discordance between Rome III and IV criteria for IBS was compared with earlier published Indian community data.

RESULTS

Of 110 clinic patients with functional gastrointestinal disorders, 72 met IBS criteria (47 [42.7%], 22 [20%] and three [2.7%] both Rome III and IV criteria, Rome III criteria only and Rome IV criteria only, respectively). In contrast, of 40 IBS subjects from Indian community published earlier, nine (22.5%), 28 (70%) and three (7.5%) fulfilled both Rome III and IV, Rome III only, Rome IV only criteria, respectively. Clinic patients with IBS fulfilling both Rome III and IV criteria or Rome IV criteria had higher IBS-SSS than those fulfilling Rome III criteria only (295.3 ± 80.7 vs. 205.6 ± 65.7; p < 0.00001). This difference was primarily related to pain severity and number of days with pain.

CONCLUSION

Discordance between Rome IV and Rome III criteria in tertiary care clinic patients is less than in community subjects with IBS in India.

Specific probiotics and prebiotics to improve the quality of life of patients with chronic irritable bowel syndrome

BACKGROUND

Irritable bowel syndrome (IBS) is a chronic disorder with an important impact on patients' quality of life. Although several data indicate that psychological symptoms are frequently reported by patients with IBS, few therapies have been evaluated regarding these issues.

METHODS

A retrospective observational study was conducted to evaluate the effectiveness of a probiotic-based dietary supplement (Colicron®) in a group of patients with diarrhea-predominant IBS (IBS-D). We included patients treated with Colicron® (1 cps/day for 8 weeks). Primary endpoint was the gastrointestinal symptoms' remission evaluated by Visual Analogue Scale (VAS); secondary endpoint was the impact of the treatment on physical and mental health evaluated by Hospital Anxiety and Depression Score (HADS) and Short Form Health Survey 36 (SF-36). VAS was assessed at week 4 (T4), week 8 (T8) and week 12 (T12), whereas HADS and SF-36 were performed even at the start of the Colicron® treatment (T0).

RESULTS

An improvement of VAS Score was observed at T8 (P<0.001) and T12 (P<0.05) compared to T4. Lower HADS-A (anxiety subdomain) score was obtained at each time point versus T0 (P<0.01), and higher scores of all SF-36 domains were observed during the treatment (0.05

CONCLUSIONS

Colicron® could be useful in improving both gastrointestinal and psychological symptoms in IBS-D patients. Further prospective clinical trials are needed to confirm these preliminary data.

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Key Words Collapse

MESH Headings

• Humans
• Irritable Bowel Syndrome/psychology
• Irritable Bowel Syndrome/therapy
• Irritable Bowel Syndrome/complications
• Quality of Life
• Probiotics/therapeutic use
• Female
• Male
• Retrospective Studies
• Adult
• Middle Aged
• Prebiotics
• Chronic Disease
• Treatment Outcome
• Anxiety/etiology
• Diarrhea
• Depression/etiology
• Dietary Supplements

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Grants Collapse

Affiliation(s)

Lorenzo Bertani Department of General Surgery and Gastroenterology, Tuscany North West ASL, Hospital of Pontedera, Pontedera, Pisa, Italy -
Linda Balestrini Laboratori Aliveda srl, Crespina Lorenzana, Pisa, Italy
Lucia Chico Laboratori Aliveda srl, Crespina Lorenzana, Pisa, Italy
Giulia Della Scala Laboratori Aliveda srl, Crespina Lorenzana, Pisa, Italy
Francesca Geri Department of General Surgery and Gastroenterology, Tuscany North West ASL, Hospital of Pontedera, Pontedera, Pisa, Italy
Alessandro Tornar Department of General Surgery and Gastroenterology, Tuscany North West ASL, Hospital of Pontedera, Pontedera, Pisa, Italy
Claudio Belcari Department of General Surgery and Gastroenterology, Tuscany North West ASL, Hospital of Pontedera, Pontedera, Pisa, Italy

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Personalisation of therapy in irritable bowel syndrome: a hypothesis

Irritable bowel syndrome (IBS) is a common disorder of gut-brain interaction characterised by symptoms of abdominal pain, occurring at least 1 day per week, and a change in stool frequency or form. Individuals with IBS are usually subtyped according to their predominant bowel habit, which is used to direct symptom-based treatment. However, this approach is probably an oversimplification of a complex and multidimensional condition, and other factors, such as psychological health, are known to influence symptom severity and prognosis. We have previously used latent class analysis, a method of mathematical modelling, to show that people with IBS can be classified into seven unique clusters based on a combination of gastrointestinal symptoms, abdominal pain, extraintestinal symptoms, and psychological comorbidity. The clusters can be used to predict the prognosis of IBS (eg, symptom severity), health-care use (eg, consultation behaviour, prescribing, and costs), and impact (eg, quality of life, work and productivity, activities of daily living, and income). These clusters could also be used to increase the personalisation of IBS treatment that better recognises the heterogenous nature of the condition. We present new data providing additional validation of our seven-cluster model and conduct a comprehensive evidence-based review of IBS management. Based on this evidence, we propose a framework of first-line and second-line treatments according to IBS cluster. Finally, we discuss what further research is needed to implement this approach in clinical practice, including the need for randomised trials comparing cluster-based treatment with conventional treatment according to stool subtype.

Dietary management of irritable bowel syndrome: considerations, challenges, and solutions

Diet is a cornerstone in the management of irritable bowel syndrome (IBS). There is evidence of efficacy across the spectrum of dietary management strategies, including some supplements (eg, specific fibres), foods, and whole diets (eg, a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols [known as the low-FODMAP diet]). Whole-diet interventions, in particular those that restrict intake, can be challenging to deliver effectively and safely. Factors to consider include patient demographics, food cost and availability, and the acceptability of dietary management and its impact on food-related quality of life. There is concern regarding a potential role of restrictive whole-diet interventions in eating disorder risk. Optimal approaches to delivering dietary management in the health-care setting are unclear. The aim of this Review is to summarise the clinical evidence for the dietary management of IBS; to discuss the challenges, burdens, and risks of dietary management; and to propose how these challenges, burdens, and risks should be mitigated and minimised in clinical practice.

Chinese Herbal Medicine for Irritable Bowel Syndrome: A Perspective of Local Immune Actions

Irritable bowel syndrome (IBS) is the functional gastrointestinal disorder, characterized by abdominal pain and altered bowel habits. The interest in intestinal immune activation as a potential disease mechanism for IBS has increased exponentially in recent years. This study was designed to summarize the Chinese herbal medicine (CHM) that potentially exert protective effects against IBS through inhibition of intestinal immune activation. We detailed the current evidence that immune activation contributes to the pathology of IBS and discussed the potential mechanisms involved. Then, therapeutic effects and possible mechanisms related to immune response of herbal medicine prescriptions, extracts, and monomers were analyzed. The reasons leading to the aberrant and persistent immune activation noted in IBS are mainly associated with the increased number of mast cells, CD3[Formula: see text] T cells, and CD4[Formula: see text] T cells. The mechanisms mainly focused on the gut microbiota disorder induced alteration of the PGE2/COX2/SERT/5-HT, TLR4/MyD88/NF-κB, and BDNF/TrkB pathways. Most of the CHM alleviated IBS through interventions of intestinal immune activation via gut microbiota related to the TLR4/MyD88/NF-κB and SCF/c-kit pathways. We hope this review will provide some clues for the further development of novel candidate agents for IBS and other intestinal immune disorders.

A Phase II, Multicentric, Randomized, Double-Blind, Placebo-Controlled, Proof of Concept Study of Efficacy and Safety of Rifamycin SV-MMX 600 mg Tablets Administered Three or Two Times Daily to Patients With Diarrhea-Predominant Irritable Bowel Syndrome

INTRODUCTION

Treatment with nonresorbable antibiotics is effective in diarrhea-predominant irritable bowel syndrome (IBS-D). Multimatrix (MMX) formulations ensure targeted drug delivery to the mid-distal small bowel and colon-traditionally considered the origin of IBS symptoms. To assess the efficacy of rifamycin SV-MMX for the treatment of IBS-D.

METHODS

Randomized controlled trial in patients with IBS-D (Rome IV). Patients received rifamycin SV-MMX 600 mg (b.i.d = 1200 mg/d or t.i.d = 1800 mg/d) or placebo for 2 weeks. Primary end point was responder rate in the first treatment week on the full analysis set (FAS). Response was defined as decrease in average abdominal pain ≥ 30% AND ≥50% reduction of days with stool type 6 or 7 based on daily reporting.

RESULTS

A total of 279 patients were randomized (=ITT), and 264 of were included in the FAS. More patients with rifamycin SV-MMX b.i.d (22/88, 25.00%) met the primary end point than t.i.d (10/81, 12.35%) or placebo (9/95, 9.47%) in both FAS and ITT. Adjusted odds ratio (AOR) for b.i.d. vs placebo was 3.26 (95% confidence interval (CI): 1.39-7.67; P = 0.007) and for t.i.d. vs b.i.d. 0.40 (95% CI: 0.17-0.92; P = 0.031). After treatment, the percentage of monthly global responders was higher in the b.i.d. group vs placebo in the first month (64.2% vs 46.6%, adjusted odds ratio = 2.14 95% CI: 1.15; 4.00; P = 0.0173) and first 2 months.

DISCUSSION

Rifamycin SV-MMX 600 mg b.i.d. was more effective than placebo and t.i.d. dosing in the first week of treatment. Two months after treatment, rifamycin SV-MMX 600 mg b.i.d. provided more global symptom relief than placebo.

A Review of Pharmacologic and Non-Pharmacologic Therapies in the Management of Irritable Bowel Syndrome: Current Recommendations and Evidence

Irritable bowel syndrome (IBS) is a highly prevalent and debilitating disorder of gut-brain interaction (DGBI) affecting millions globally. It imposes a significant burden on healthcare systems and is a leading cause of workplace absenteeism. IBS is classified into several subtypes based on predominant presenting symptoms, including IBS with constipation (IBS-C) and IBS with diarrhea (IBS-D), with each requiring targeted approaches to treatment. Some treatments, such as psychotherapy, dietary intervention, and medications like tricyclic antidepressants, are nonspecific and recommended for managing IBS symptoms across all subtypes. In contrast, therapies like secretagogues for IBS-C and eluxadoline or rifaximin for IBS-D are subtype-specific. However, many IBS treatments carry conditional recommendations and are based on low-certainty evidence, emphasizing the need for further research to expand the available treatment options. This review compares the latest IBS management guidelines from the American Gastroenterological Association (AGA), American College of Gastroenterology (ACG), British Society of Gastroenterology (BSG), and European Society for Neurogastroenterology and Motility (ESNM). Pharmacologic and non-pharmacologic therapies, including established and emerging interventions, will be explored to provide a comprehensive guide to management.

Irritable Bowel Syndrome in Veterans With Gulf War Illness Evaluated at VA's War-Related Illness and Injury Study Center

INTRODUCTION

Excess rates of Gulf War illness (GWI) and irritable bowel syndrome (IBS), two chronic multisymptom illnesses, have long been documented among nearly 700,000 veterans who served in the 1990-1991 Persian Gulf War. We sought to report the prevalence, characteristics, and association of GWI and IBS decades after the war in a clinical cohort of deployed Gulf War veterans (GWVs) who were evaluated at the Department of Veterans Affairs' War Related Illness and Injury Study Center (WRIISC) for unexplained chronic symptoms.

MATERIALS AND METHODS

We analyzed data gathered from clinical intake questionnaires of deployed GWVs who were evaluated at WRIISC clinics between 2008 and 2020. We applied Centers for Disease Control (CDC) criteria to determine the prevalence of severe GWI. IBS was identified using Rome IV diagnostic criteria (current IBS) and veterans' self-reported "history of physician-diagnosed IBS." We examined associations between IBS and GWI using bivariate analyses and multivariable logistic regression.

RESULTS

Among the N = 578 GWVs evaluated by the WRIISC, severe GWI (71.8%), history of physician-diagnosed IBS (50.3%) and current IBS (42.2%) were all highly prevalent. Nearly half of GWVs with severe GWI met Rome criteria for IBS (45.8%), and over half reported a history of physician-diagnosed IBS (56.1%). In multivariable models, severe GWI was significantly associated both with current IBS (adjusted odds ratio (aOR): 1.68, 95% CI: 1.11, 2.54) and with veteran-reported history of physician-diagnosed IBS (aOR: 2.15, 95% CI: 1.43, 2.23). IBS with diarrhea (IBS-D) was the most common subtype among GWVs with current IBS (61.1%). However, IBS-mixed affected a significantly greater proportion of veterans with severe GWI, compared to veterans who did not have severe GWI (P = .03).

CONCLUSIONS

More than 20 years after the Persian Gulf War, our findings indicate a high degree of comorbidity between severe GWI and IBS among deployed GWVs seeking care for unexplained illnesses. Our results suggest GWVs with GWI should be screened for IBS for which evidence-based treatments are available and could potentially reduce symptom burden. Conversely, symptoms of IBS should trigger additional evaluation for non-gastrointestinal symptoms in deployed Gulf War veterans to identify possible GWI and ensure a comprehensive approach to care.

Review article: The role of the gut-brain axis in inflammatory bowel disease and its therapeutic implications

BACKGROUND

Treatments targeting the gut-brain axis (GBA) are effective at reducing symptom burden in irritable bowel syndrome (IBS). The prevalence of common mental disorders and IBS-type symptom reporting is significantly higher in inflammatory bowel disease (IBD) than would be expected, suggesting potential GBA effects in this setting. Manipulation of the GBA may offer novel treatment strategies in selected patients with IBD. We present a narrative review of the bi-directional effects of the GBA in IBD and explore the potential for GBA-targeted therapies in this setting.

METHODS

We searched MEDLINE, EMBASE, EMBASE Classic, PsychINFO, and the Cochrane Central Register of Controlled Trials for relevant articles published by March 2024.

RESULTS

The bi-directional relationship between psychological well-being and adverse longitudinal disease activity outcomes, and the high prevalence of IBS-type symptom reporting highlight the presence of GBA-mediated effects in IBD. Treatments targeting gut-brain interactions including brain-gut behavioural treatments, neuromodulators, and dietary interventions appear to be useful adjunctive treatments in a subset of patients.

CONCLUSIONS

Psychological morbidity is prevalent in patients with IBD. The relationship between longitudinal disease activity outcomes, IBS-type symptom reporting, and poor psychological health is mediated via the GBA. Proactive management of psychological health should be integrated into routine care. Further clinical trials of GBA-targeted therapies, conducted in selected groups of patients with co-existent common mental disorders, or those who report IBS-type symptoms, are required to inform effective integrated models of care in the future.

Practices and Barriers in Implementing the Low FODMAP Diet for Irritable Bowel Syndrome Among Malaysian Dietitians: A Qualitative Study

The low fermentable oligo-, di-, mono-saccharides and polyols (FODMAP) diet (LFD) is a second-line dietary intervention for irritable bowel syndrome (IBS) patients, involving FODMAP restriction, reintroduction, and personalization, and it needs to be delivered by dietitians. However, the application of this diet among Malaysian IBS patients is not well understood. This study aimed to explore the practices and barriers in delivering the LFD among Malaysia dietitians. Semi-structured qualitative interviews were conducted online with practicing dietitians until the data reached saturation. All the interview sessions were audio recorded and transcribed verbatim. Thematic analysis was used to analyze the data. Eleven dietitians were interviewed, with 36.4% (n = 4) having more than 10 years of experience. The following four themes regarding their practices emerged: 1. dietary advice on FODMAP restriction; 2. duration of FODMAP restriction phase; 3. references used to get information about FODMAPs, and 4. strategies on reintroduction. Meanwhile, the following seven barriers were identified: 1. lack of culturally relevant educational materials; 2. limited knowledge about the LFD; 3. inadequate formal training among dietitians; 4. lack of integration in multi-disciplinary care; 5. low health literacy of patients; 6. low compliance rate among patients, and 7. restrictions for certain populations. LFD implementation in Malaysia is not standardized as only experienced dietitians can provide dietary evidence-based advice. Lack of training and culturally specific resources are some of the main barriers that were identified to be limiting the implementation of the diet. Therefore, there is a need for training programs and resource development to support Malaysian dietitians in managing IBS patients.

Probiotics and Prebiotics for the Treatment of Irritable Bowel Syndrome-A Narrative Review

Background/Objectives: Gastrointestinal functional disorders (GFDs), including irritable bowel syndrome (IBS), are imbalances in the gut-brain axis characterized by persistence of symptoms in the abdominal area. Probiotics are live microorganisms that provide benefits to the health of their hosts when administered in adequate amounts, while prebiotics are a substrate that is selectively used by host microorganisms. This narrative review aimed to evaluate the effectiveness of prebiotics and probiotics mostly in irritable bowel syndrome, particularly on issues such as the interaction between these products and the gut microbiota, the duration of supplementation and long-term effects, the definition of ideal dosages, and the regulation and quality control of these products. Methods: A bibliographic search was carried out in indexed databases and articles published within 10 years before the beginning of the study and publications in English language, which investigated the specific theme of the study were considered. Papers dealing with topics not covered by the research questions, or presenting errors related with the wrong population or the wrong methods, as well as experimental studies and case reviews were excluded. Fifty-five articles were selected, initially in isolation by the authors and, afterward, under consensus. Results: It was possible to observe the effectiveness mainly of probiotics, in improving specific symptoms of the respective disorder; however, the available data remain unclear due to limitations concerning samples and methods of the studies evaluated. Conclusions: Despite evidence suggestive of therapeutic efficacy, additional multicenter randomized controlled trials (RCTs) with better defined protocols are still necessary to fill in the gaps in this subject, define measures to ensure the safe administration of these products, and confirm their therapeutic potential.

Impact of Enteric Nervous Cells on Irritable Bowel Syndrome: Potential Treatment Options

Irritable bowel syndrome (IBS) is a condition that significantly impacts the lifestyle, health, and habits of numerous individuals worldwide. Its diagnosis and classification are based on the Rome criteria, updated periodically to reflect new research findings in this field. IBS can be classified into different types based on symptoms, each with distinct treatment approaches and some differences in their pathophysiology. The exact pathological background of IBS remains unclear, with many aspects still unknown. Recent research developments suggest that disorders in the brain-gut-microbiota axis are key contributors to the symptoms and severity of IBS. The central nervous system (CNS) interacts bidirectionally with intestinal processes within the lumen and the intestinal wall, with the autonomic nervous system, particularly the vagus nerve, playing an important role. However, the enteric nervous system (ENS) is also crucial in the pathophysiological pathway of IBS. The apeline-corticotropin-releasing factor (CRF)-toll-like receptor 4 (TLR4) signaling route via enteric glia and serotonin production in enteroendocrine cells at the enteric barrier are among the most well-understood new findings that affect IBS through the ENS. Additionally, the microbiota regulates neuronal signals, modifying enteric function by altering the number of enteric bacteria and other mechanisms. Given the limited therapeutic options currently available, it is essential to identify new treatment targets, with the brain-gut axis, particularly the enteric nervous system, being a promising focus. This study aims to delineate the molecular mechanisms that induce IBS and to suggest potential targets for future research and treatment of this potentially debilitating disease.

Adapted Low-FODMAP Diet in IBS Patients with and without Fibromyalgia: Long-Term Adherence and Outcomes

BACKGROUND/OBJECTIVES

A low-FODMAPs Diet (LFD) is considered a "second line" dietary strategy for irritable bowel syndrome (IBS) but, after a period of strict restriction of all FODMAP foods, it has to be adapted and tailored to each patient (AdLFD). Fibromyalgia often coexists with IBS in up to 65% of cases. Our aims were to evaluate if comorbid fibromyalgia influenced the long-term clinical outcomes and adherence to an AdLFD in IBS patients.

METHODS

IBS patients with or without fibromyalgia who had started an AdLFD were enrolled. Patients had been evaluated before starting the LFD (T0). After a mean follow-up of 62.5 ± 22.7 months (T1), they were re-evaluated using questionnaires on disease severity, bowel habits, psychological status, and adherence to AdLFD.

RESULTS

In total, 51 IBS patients entered the study. Nineteen of them had comorbid fibromyalgia. Thirty patients reported a reduction in symptom severity at T1 in comparison with T0. Despite some slight differences in single IBS Symptom Severity Score items, comorbid fibromyalgia did not influence the IBS-SSS total score at T1. Patients with comorbid fibromyalgia showed a higher Hospital Anxiety and Depression Scale (HADS) score at baseline. A total of 44 patients showed good long-term adherence to the AdLFD. All patients improved their HADS score and had long-term adherence to the AdLFD.

CONCLUSIONS

Comorbid fibromyalgia showed only a slight influence on long-term outcomes of an AdLFD on IBS symptoms, without affecting the relief of global symptoms. No influence on long-term adherence to AdLFD was detected. Hence, this approach can be taken into account in fibromyalgia patients for a nonpharmacological management of IBS symptoms. However, multicentric studies on larger samples would be welcome in the future.