International Consensus Targets IBS-Like Symptoms in Inflammatory Bowel Disease
Key Clinical Summary
- Inflammatory bowel disease with irritable bowel syndrome–like symptoms affects an estimated 20%–30% of patients with IBD in remission.
- A 13-member international panel rated 86 of 105 consensus statements appropriate, supporting objective assessment of inflammation before treatment escalation.
- >Recommended options include short-term low-FODMAP diets, psyllium, symptom-directed medications, neuromodulators, gastrointestinal-focused cognitive behavioral therapy, and gut-directed hypnotherapy.
A joint Rome Foundation and International Organization for the Study of IBD consensus published in Gastroenterology provides a framework for evaluating and treating persistent gastrointestinal symptoms in patients with Crohn disease or ulcerative colitis.
The recommendations distinguish IBS-like symptoms from uncontrolled inflammation and emphasize therapies matched to the presumed symptom mechanism.
Findings and Recommendations
Using a modified RAND/UCLA Appropriateness Method, 13 international experts evaluated statements addressing terminology, diagnosis, dietary treatment, pharmacotherapy, and brain-gut behavioral interventions. Among 105 statements reaching final scoring, 86 were rated appropriate, 16 uncertain, and 3 inappropriate.
For clinical practice, the panel supported applying Rome symptom criteria after appropriately excluding active inflammation through biomarkers, endoscopy, histology, or imaging. Proposed research thresholds included a Simple Endoscopic Score for Crohn’s Disease below 4, a Mayo endoscopic subscore of 0 or 1 for ulcerative colitis, and fecal calprotectin below 150 μg/g.
Treatment recommendations included psyllium when clinically relevant strictures are absent and a short-term diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols. Pharmacologic options should reflect the predominant symptom: antidiarrheals or laxatives, 5-HT3 antagonists for diarrhea, and secretagogues or 5-HT4 agonists for constipation when no stricture is present.
Clinical Implications
The consensus cautions against automatically interpreting persistent gastrointestinal symptoms as evidence of active IBD. Objective reassessment can help clinicians avoid unnecessary escalation of corticosteroids, immunomodulators, biologics, or small-molecule therapies when inflammation or structural complications do not adequately explain the symptom burden.
Tricyclic antidepressants received the strongest support among neuromodulators. Selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors may also be considered according to bowel pattern and coexisting anxiety or depression; antispasmodics and peppermint oil were rated appropriate.
Gastrointestinal-focused cognitive behavioral therapy and gut-directed hypnotherapy received unanimous appropriate ratings. The panel supported incorporating these brain-gut behavioral interventions earlier in care rather than reserving them for patients who have exhausted other options.
Limitations included inconsistent definitions of remission; few large randomized trials conducted specifically in this population; limited mechanistic phenotyping; and reliance on extrapolation from IBS studies. The predominantly North American panel may also limit global generalizability.
Expert Commentary
Senior author Lin Chang, MD, of the David Geffen School of Medicine at UCLA in Los Angeles, and colleagues framed “IBD with IBS-like symptoms” as a distinct clinical phenotype. Their consensus supports a positive, mechanism-informed diagnosis after appropriate inflammatory and structural assessment, followed by treatment directed toward the patient’s predominant symptoms rather than reflexive escalation of IBD therapy.
The recommendations provide clinicians with a structured approach to a common but underrecognized problem in Crohn disease and ulcerative colitis. Further trials are needed to validate specific therapies, refine mechanistic phenotypes, and establish standardized remission definitions.
Reference
Ma C, Ford AC, Hashash JG, et al. Recommendations for the evaluation and management of inflammatory bowel disease with irritable bowel syndrome-like symptoms: a joint Rome Foundation and International Organization for the Study of IBD (IOIBD) consensus. Gastroenterology. 2026;171(3):504-520. doi:10.1053/j.gastro.2026.04.008
