How doctors will diagnose, treat, and manage IBS in the near future



Earlier this year, the American College of Gastroenterology (ACG) published its recommendations of how physicians should diagnose and treat people with IBS. This is the first time that the ACG has issued a set of guidelines on the topic. They indicate that these recommendations have been based on a review of hundreds of clinical studies. The ACG is now in the process of informing physicians of their recommendations.


By doing so, we hope to provide a roadmap for physicians to use when treating patients with IBS,” said William D. Chey, MD, FACG.


IBSLife editors are sharing this news so readers can best collaborate with their physicians to come up with an updated plan that works best for them. The following lists some of the guidelines from the ACG. For the complete list, visit: https://bit.ly/3vu8faW.


Diagnosing IBS. The ACG indicates that physicians no longer need to order a complete blood count, serum chemistries, thyroid function testing, stool and parasites examination, and abdominal imaging as part of their diagnostic process. That’s because they believe there is very little risk that IBS caused significant damage to tissue, which is what some of these tests are meant to reveal. The one exception? Physicians should still consider ordering a serologic screening (which looks for antibodies) for those they suspect might have either IBS-D or IBS-M. The screening test is used to rule out celiac disease.


Physicians also do not need to order routine imaging of the colon for people younger than 50 years of age if there’s a low probability of Crohn’s disease, ulcerative colitis, or tumors in the colon.


Food Testing and/or Elimination Diet. Surprisingly, there is still not enough evidence in clinical literature about food allergy testing or elimination diets. As such, the ACG does not yet recommend this approach for treating IBS. According to the group, there aren’t enough double-blind studies — clinical trials that include a test group and a control group — for ACG to make an unbiased recommendation. Individuals who are certain that their symptoms worsen with specific food types, should still seek the guidance of a nutritionist/dietitian.


Dietary fiber and laxatives. In reviewing all data available, the ACG indicates that psyllium hydrophilic mucilloid (a powder preparation) is moderately effective in improving IBS-C symptoms. Wheat bran or corn bran is no more effective than placebo, and polyethylene glycol (Miralax) improved stool frequency.


Antispasmodics. Medications used to treat stomach pains and cramps have shown symptom improvement in the short term. However, there are no studies that focus on long term symptom relief. Commonly used antispasmodics include Bentyl (dicyclomine), Levsin (hyoscyamine), and peppermint oil. All of which, according to ACG, can be effective IBS treatments.


Antidiarrheal. The ACG continues to recommend loperamide (Imodium) for diarrhea, reduction of stool frequency, and improvement of stool consistency. However, loperamide won’t work for pain, bloating, or other global IBS symptoms.


Antibiotics. Nonabsorbable antibiotics (not easily absorbed in the body) are more effective for treating bloating symptoms. An example of a nonabsorbable antibiotic is Xifaxan, which contains rifaximin.


Probiotics. Because probiotics used in clinical studies vary in the types of bacteria, strains, preparations, and doses, it’s difficult for the ACG to make a clear recommendation that probiotics are helpful. However, Bifidobacteria and some combinations of probiotics appear to be effective. Data suggest that all probiotics trend toward being effective for the treatment of IBS. The problem is that there aren’t enough long-term data.


Antidepressants. Tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs) are effective for abdominal pain and other global symptoms of IBS. According to ACG, it appears that SSRIs should have the most benefit in persons with IBS-C and tricyclics should have the most benefit in patients with IBS-D. It also appears that SSRIs are better tolerated than tricyclic antidepressants.


Psychological and cognitive behavior therapies. Psychological therapies (not including relaxation therapy) are effective in relieving IBS symptoms. Several studies also showed that there were some benefits with cognitive behavior therapy, dynamic psychotherapy, and hypnotherapy, but not with relaxation therapy. Cognitive behavior therapy is the most studied approach, with one large, high-quality trial showing benefit.


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