{"id":213,"date":"2025-01-31T13:46:21","date_gmt":"2025-01-31T13:46:21","guid":{"rendered":"https:\/\/blogs.bmj.com\/gut\/?p=213"},"modified":"2025-01-31T13:46:21","modified_gmt":"2025-01-31T13:46:21","slug":"gutblog-recent-advances-in-clinical-practice-mastering-the-challenge-managing-ibs-symptoms-in-ibd","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/gut\/2025\/01\/31\/gutblog-recent-advances-in-clinical-practice-mastering-the-challenge-managing-ibs-symptoms-in-ibd\/","title":{"rendered":"#GUTBlog: Recent advances in clinical practice: mastering the challenge\u2014managing IBS symptoms in IBD"},"content":{"rendered":"

Professor El-Omar has selected Dr Judith Wellens and Professor S\u00e9verine Vermeire from the Department of\u00a0Gastroenterology and Hepatology<\/span>,\u00a0KU Leuven University Hospitals Leuven Gasthuisberg Campus Hospital Pharmacy,\u00a0Leuven<\/span>, Belgium<\/span>\u00a0to do the next #GUTBlog<\/a>. Dr Judith Wellens is the first author and Professor Vermeire is the senior author.<\/p>\n

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The authors of this paper from left to right: Prof Dr Jan Tack, Prof Dr Jo\u00e3o Sabino, Dr Judith Wellens, Prof Dr S\u00e9verine Vermeire, Prof Dr Tim Vanuytsel<\/figcaption><\/figure>\n

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The\u00a0#GUTBlog<\/a> focusses on the paper\u00a0\u201cRecent advances in clinical practice: mastering the challenge\u2014managing IBS symptoms in IBD\u201d which was published in paper copy in GUT in February 2025.<\/a><\/p>\n

Dr Judith Wellens, Professor S\u00e9verine Vermeire et al write:<\/a><\/p>\n

“Introduction<\/strong><\/p>\n

Inflammatory Bowel Disease (IBD) and Irritable Bowel Syndrome (IBS) are distinct conditions often managed as separate entities. According to the ROME IV criteria, a patient with IBD cannot simultaneously be diagnosed with IBS. However, in clinical practice, many physicians recognize symptoms reminiscent of IBS when treating patients with IBD. Approximately one-quarter of IBD patients in remission report persistent symptoms such as abdominal pain, urgency, and frequent bowel movements, resulting in a decreased quality of life and increased healthcare utilization.<\/p>\n

This issue is becoming even more relevant as advances in the IBD therapeutic armamentarium have enabled more ambitious goals including endoscopic remission. Yet, these outcomes do not consistently translate into relief of gastrointestinal symptoms, and highlight a diagnostic and clinical challenge that has garnered growing interest from the scientific and clinical community.<\/p>\n

Guided by our clinical experience and a commitment to improving patient care, we sought to explore a couple of key questions: How prevalent are IBS symptoms in patients with IBD? What is their impact on patients\u2019 lives? What underlying mechanisms contribute to persistent IBS symptoms in patients with IBD in remission, and how should this be addressed? To answer these questions, we critically reviewed the literature to provide an updated overview of the epidemiology, pathophysiology, diagnostic approaches, and management strategies for IBS-like symptoms in IBD patients.<\/a><\/p>\n

Epidemiology and Impact<\/strong><\/p>\n

Regarding the size of the problem and its impact, a meta-analysis of 3,169 IBD patients in remission revealed that 32.5% experienced IBS-like or non-inflammatory symptoms (1). Even when applying stringent histological remission criteria, the prevalence remained as high at 25.8%. These symptoms were more common in Crohn\u2019s disease (CD, 36.6%), compared to ulcerative colitis (UC, 28.7%). These figures far exceed the global IBS prevalence of 5-10%, underscoring a significant burden of non-inflammatory symptoms in IBD (2).<\/p>\n

Pathophysiological Considerations<\/strong><\/p>\n

Why is there such a significant disparity between IBS prevalence in the general population and IBS-like symptoms in IBD? While occult inflammation and pre-existing IBS before IBD diagnosis have long been considered to be contributing factors, longitudinal studies looking into risk of hospitalization or escalation of therapy suggest these explanations may be less critical. These findings have therefore shifted the research agenda towards other potential mechanisms.<\/p>\n

Emerging research highlights shared pathophysiological factors between IBD and IBS, including genetic predisposition and environmental influences such as diet. Furthermore, mucosal barrier dysfunction and inflammation, hallmarks of both conditions, may create a foundation for overlap. A psychological susceptibility, for anxiety or depression, and the bidirectional gut-brain axis, are also pivotal in understanding IBS-like symptoms in IBD as explained in detail in the manuscript.<\/p>\n

Diagnostic Approaches<\/strong><\/p>\n

In \u2018Figure 2<\/em>\u2019, we propose a clinical diagnostic framework tailored to patients\u2019 primary complaints, such as constipation, diarrhea, pain, or bloating. This approach allows clinicians to identify the symptom which is most predominant to efficiently guide first-line treatment. Crucially, occult inflammation must be excluded early in the diagnostic process. Additionally, psychological co-morbidities should be addressed early on as part of the overall management strategy.<\/a><\/p>\n

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Figure 2 from the paper: Practical approach to the diagnosis and management of persisting symptoms in patients with IBD in deep remission. This approach focuses on the main complaint, is mindful of specific possible explanations in patients with IBD and fully integrates psychological aspects. IBS-C, constipation-predominant irritable bowel syndrome; IBS-D, diarrhoea-predominant irritable bowel syndrome; IBS-M, irritable bowel syndrome with mixed bowel habits; IUS, intestinal ultrasound; SIBO, small intestinal bacterial overgrowth.<\/a><\/figcaption><\/figure>\n

 <\/p>\n

Treatment Strategies<\/strong><\/p>\n

In \u2018Figure 3<\/em>,\u2019 we outline evidence-based treatment options for IBS-like symptoms in IBD, categorized by their level of evidence and their position along the gut-brain axis. Effective management requires a multimodal approach combining classical pharmacological treatments, emerging non-classical agents, lifestyle modifications, and microbiota-based therapies.<\/a><\/p>\n

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Figure 3 (from the paper): Categories of current treatment options to treat IBS-like symptoms in IBD on top of general lifestyle advice. Therapies can be classified as acting more centrally, peripherally or at the intersection between brain and gut. CAMs, complementary and alternative medicine; FODMAP, fermentable oligosaccharides, disaccharides, monosaccharides and polyols; SSRI, selective serotonin reuptake inhibitor; SNRI, serotonin and norepinephrine reuptake inhibitor; TCA, tricyclic antidepressant; SSRI, selective serotonin reuptake inhibitor; SNRI, serotonin and norepinephrine reuptake inhibitor.<\/a><\/figcaption><\/figure>\n

 <\/p>\n

Future Directions and Conclusion<\/strong><\/p>\n

We also discuss treatment goals and future research directions, emphasizing the importance of a multidisciplinary approach. In the ideal scenario, IBS-like symptoms in IBD patients should be managed by gastroenterologists with expertise in both domains or through close collaboration between specialists. Our proposed clinical algorithm to guide diagnosis and treatment can be the first step to ensure patient-centered care in the management of non-inflammatory symptoms in IBD.<\/a><\/p>\n

References<\/strong><\/p>\n

(1) Fairbrass KM, Costantino SJ, Gracie DJ, et al. Prevalence of irritable bowel syndrome-type symptoms in patients with inflammatory bowel disease in remission: a systematic review and meta-analysis. Lancet Gastroenterol Hepatol 2020;5:1053\u20131062.<\/p>\n

(2) Oka P, Parr H, Barberio B, et al. Global prevalence of irritable bowel syndrome according to Rome III or IV criteria: a systematic review and meta-analysis. Lancet Gastroenterol Hepatol 2020;5:908\u2013917.<\/p>\n

Social Media<\/strong><\/p>\n

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@JudithWellens<\/div>\n<\/div>\n
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@JoaoPGSabino<\/div>\n<\/div>\n
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@VanuytselTim<\/div>\n<\/div>\n
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@SeverineVermei1<\/div>\n<\/div>\n
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@ibdleuven<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"

Professor El-Omar has selected Dr Judith Wellens and Professor S\u00e9verine Vermeire from the Department of\u00a0Gastroenterology and Hepatology,\u00a0KU Leuven University Hospitals Leuven Gasthuisberg Campus Hospital Pharmacy,\u00a0Leuven, Belgium\u00a0to do the next #GUTBlog. Dr Judith Wellens is the first author and Professor Vermeire is the senior author.   The\u00a0#GUTBlog focusses on the paper\u00a0\u201cRecent advances in clinical practice: mastering […]<\/p>\n

Read More…<\/a><\/p>\n","protected":false},"author":413,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"image","meta":{"footnotes":""},"categories":[6,7],"tags":[],"class_list":["post-213","post","type-post","status-publish","format-image","hentry","category-gutblog","category-ibd","post_format-post-format-image"],"_links":{"self":[{"href":"https:\/\/blogs.bmj.com\/gut\/wp-json\/wp\/v2\/posts\/213","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.bmj.com\/gut\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.bmj.com\/gut\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.bmj.com\/gut\/wp-json\/wp\/v2\/users\/413"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.bmj.com\/gut\/wp-json\/wp\/v2\/comments?post=213"}],"version-history":[{"count":0,"href":"https:\/\/blogs.bmj.com\/gut\/wp-json\/wp\/v2\/posts\/213\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.bmj.com\/gut\/wp-json\/wp\/v2\/media?parent=213"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.bmj.com\/gut\/wp-json\/wp\/v2\/categories?post=213"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.bmj.com\/gut\/wp-json\/wp\/v2\/tags?post=213"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}