Professor El-Omar has chosen Dr Dipesh Vasant, Consultant Gastroenterologist from the Neurogastroenterology Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK and Professor Alexander Ford, Professor of Gastroenterology, from the Leeds Gastroenterology Institute, St. James’s University Hospital, Leeds, UK – on behalf of the ‘British Society of Gastroenterology‘ Guidelines on the Management of Irritable Bowel Syndrome Group – do do the next #GUTBlog.

“The previous edition of the British Society of Gastroenterology guidelines for the management of irritable bowel syndrome (IBS) were published in 2007.¹We recognised the considerable practice-changing advances in epidemiology, pathophysiology, diagnostic criteria, overall management approach, and the evidence-base for dietary, medical, and psychological treatments for IBS. For example, in 2021, it is difficult for practicing gastroenterologists to contemplate not having access to established tests, such as faecal calprotectin, interventions such as a diet low in fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs), and effective medical treatments, such as secretagogues which, amongst several other advances, were not available in 2007.

IBS remains one of the most common conditions seen by gastroenterologists, hence the need for contemporary, comprehensive, yet practical, guidelines as a reference for clinical practice. In line with modern understanding of IBS as a multifactorial disorder of gut-brain interaction requiring an integrated multidisciplinary approach², a multidisciplinary guidelines group was assembled with representation and input from patient bodies and representatives, primary care, secondary and tertiary care gastroenterology, clinical psychology, physiology, and nutrition and dietetics (see photo for some of the group). Rather than focusing on mechanistic aspects, a conscious effort was made to provide a concise, clinically focused review of the current understanding of IBS pathophysiology. Importantly, recognising that the majority of IBS is managed in primary care by general practitioners, the guidelines also cover the approach to the diagnosis and management of IBS in this setting.

The guidelines group felt it would be particularly important to provide a clinical definition of IBS more suitable for making a diagnosis in primary and secondary care, rather than applying the more restrictive Rome IV criteria, which were felt to be more useful in a research setting than in clinical practice. This more pragmatic clinical definition, based upon the NICE guidelines criteria for IBS, is defined as abdominal pain or discomfort, in association with altered bowel habit, for at least 6 months, in the absence of alarm symptoms or signs.

A particular strength of these guidelines is that the treatment recommendations made throughout are underpinned by updated pairwise and network meta-analyses³. The provision of stepwise guides for the diagnosis of IBS and exclusion of IBS mimics, and an evidence-based treatment algorithm for first-line and second-line treatments, as well as refractory symptoms, is intended to be of practical benefit, and can be used as quick reference materials in the clinic setting. The treatment recommendations also provide advice and support to clinicians, particularly when recommending a trial of probiotics, dietary therapies, or prescribing second-line medications such as gut-brain neuromodulators, 5-HT₃agonists including ondansetron, and rifaximin, which are licensed for other conditions, but have shown efficacy in IBS. The guidelines also reflect the accumulating evidence for IBS-specific cognitive behavioural therapy and gut-focused hypnotherapy⁴, which are recommended strongly, either following failure to respond to 12 months of drug treatment or earlier, based upon patient preference and local availability³.

Most clinicians reading this blog will have encountered, or will be caring for, a number of patients with IBS with severe or refractory symptoms. An expert opinion section dealing with this scenario was therefore included in the guidelines. This is an area where there is a lack of evidence to assist clinicians dealing with this difficult situation, with the overarching aims being to avoid iatrogenic harm, recommend a multidisciplinary care approach, and consider augmentation with combination neuromodulators.

Finally, the guidelines have also highlighted a number of important areas for future research and development. Overall, these guidelines, developed by a multidisciplinary team, provide a contemporary, practical, evidence-based approach to the diagnosis and management of IBS. We sincerely hope that clinicians find it useful in their practice. Dr. Vasant and Professor Ford would like to acknowledge and thank all the contributors and co-authors of these guidelines.

REFERENCES

1. Spiller R, Aziz Q, Creed F, et al. Guidelines on the irritable bowel syndrome: mechanisms and practical management. Gut 2007;56(12):1770-98.
2. Basnayake C, Kamm MA, Stanley A, et al. Standard gastroenterologist versus multidisciplinary treatment for functional gastrointestinal disorders (MANTRA): an open-label, single-centre, randomised controlled trial. The Lancet Gastroenterology & Hepatology 2020;5(10):890-899.
3. Vasant DH, Paine PA, Black CJ, et al. British Society of Gastroenterology guidelines on the management of irritable bowel syndrome. Gut 2021.
4. Black CJ, Thakur ER, Houghton LA, Quigley EMM, Moayyedi P, Ford AC. Efficacy of psychological therapies for irritable bowel syndrome: systematic review and network meta-analysis. Gut 2020;69(8):1441-1451.

Twitter: @DipeshVasant @alex_ford12399