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ACG Clinical Guideline 2021: Management of Irritable Bowel Syndrome

Jeffrey Roberts

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Jeffrey Roberts

An updated American College of Gastroenterology (ACG) Guideline (2021) for IBS was just published. Among the 25 recommendations for IBS from the ACG are:

  • Serologic testing should be performed to rule out celiac disease in patients with IBS and diarrhea symptoms.
  • Fecal calprotectin, fecal lactoferrin and C-reactive protein should be checked in patients without alarm features and with suspected symptoms of IBS and diarrhea to rule out inflammatory bowel disease 
  • Routine stool testing should not be performed for enteric pathogens in all IBS patients.
  • Routine colonoscopy should not be performed in patients with IBS symptoms aged younger than 45 years without warning signs. 
  • A positive diagnostic strategy vs. a diagnostic strategy of exclusion should be used for patients with IBS symptoms to improve time to initiate appropriate therapy and cost-effectiveness. 
  • Do not test for food allergies and sensitivities unless patients have reproducible symptoms concerning a food allergy.
  • Limited trial of a low fermentable oligosaccharides, disacchardies, monosaccharides, polyols (FODMAP) diet in patients with IBS to improve global symptoms.
  • Anorectal physiology testing should be performed in patients with IBS and symptoms that may suggest a pelvic floor disorder and refractory constipation.
  • Anti-spasmodics available in the United States should be used to treat global IBS.
  • Peppermint may be used to provide relief of global symptoms. 
  • Mixed opioid agonists/antagonists should be used to treat global IBS-D symptoms
  • Use of chloride channel activators and guanylate cyclase activators (Linzess / Constella) to treat global IBS with constipation symptoms.
  • Use of rifaximin (Xifaxan) to treat global IBS with diarrhea symptoms.
  • Gut-directed psychotherapy (CBT) be used to treat global IBS symptoms.



Pubmed: PMID: 33315591

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