Consensus on Irritable Bowel Syndrome-like Symptoms in Inflammatory Bowel Disease: A Step Toward Advancing Patient-Centered Care

Gastroenterology. 2026 May 25:S0016-5085(26)06931-3. doi: 10.1053/j.gastro.2026.05.013.

Abstract

Background & Aims

A substantial proportion of persons with inflammatory bowel disease (IBD) in remission continue to experience abdominal pain, altered bowel habits, and bloating that resemble irritable bowel syndrome (IBS). Lack of standardized definitions and evidence-based management strategies leads to diagnostic ambiguity and potentially unnecessary escalation of IBD therapy. A joint Rome Foundation/International Organization for the Study of Inflammatory Bowel Disease Working Team developed consensus recommendations on nomenclature, evaluation, and treatment of IBD with IBS-like symptoms.

Methods

A multidisciplinary international panel applied a modified RAND/UCLA Appropriateness Method. Systematic literature reviews informed statement generation across multiple domains: nomenclature, diagnostic and symptom assessment, dietary therapies, drugs, and brain-gut behavioral therapies. Panelists rated the appropriateness of candidate statements independently on a 9-point Likert scale, followed by anonymized feedback, discussion, and re-voting across 2 iterative rounds.

Results

Thirteen panelists reviewed 133 initial statements; 105 proceeded to final scoring. Of these, 86 were rated appropriate, 16 uncertain, and 3 inappropriate. The preferred term was “IBD with IBS-like symptoms,” defined as abdominal pain, bowel habit change, and/or bloating not explained by active inflammation or structural disease. For clinical care, diagnosis should combine Rome clinical criteria with objective exclusion of inflammation. For research, candidate thresholds for endoscopic, histologic, biomarker, and imaging remission were endorsed. Appropriate therapies include psyllium (if no stricture), a short-term low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet, targeted drugs, and brain-gut behavior therapies.

Conclusions

This first joint consensus provides standardized terminology, evaluation strategies, and treatment recommendations for IBD with IBS-like symptoms, supporting improved clinical management and guiding future mechanistic and therapeutic research.

Figure 1 Proposed pathways underlying symptom development in IBD with IBS-like symptoms. Following resolution of acute inflammation in patients with IBS, IBS-like symptoms may develop. In these patients, dysfunctional microbiota (eg, reduced microbiota diversity and imbalance) contributes to changes in epithelial integrity, increased epithelial permeability, and neuromuscular dysfunction. Although acute inflammation is downregulated (ie, neutrophil apoptosis), mild immune activation may persist. Enhanced mast cell infiltration near enteric nerves is associated with visceral hypersensitivity and symptom perception. Increased numbers of intraepithelial lymphocytes (IELs) and macrophage activation is detected in subgroups of patients. Stress, anxiety, and depression activate brain-gut pathways, participating in gut structural and functional gut changes. The activation of the hypothalamic-pituitary-adrenal axis (HPA) is involved in the downregulation inflammation and immune activation.

PMID:42191045 | DOI:10.1053/j.gastro.2026.05.013

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