World Gastroenterology Organisation (WGO) (original) (raw)

WGO

Global Guardian of Digestive Health. Serving the World.

World Gastroenterology Organisation Global Guidelines

Irritable Bowel Syndrome:

a Global Perspective

Update September 2015

Review team

Eamonn M.M. Quigley (USA, Chair)

Michael Fried (Switzerland)
Kok-Ann Gwee (Singapore)
Igor Khalif (Russia)
Pali Hungin (United Kingdom)
Greger Lindberg (Sweden)
Zaigham Abbas (Pakistan)
Luis Bustos Fernandez (Argentina)
Shobna J. Bhatia (India)
Max Schmulson (Mexico)
Carolina Olano (Uruguay)
Anton Le Mair (The Netherlands)

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1. WGO Cascades

With this guideline, the World Gastroenterology Organisation (WGO) is aiming to guide health providers in the best management of irritable bowel disease (IBS) through a concise document with recommendations based on the latest evidence and resulting from our global expert consensus process based on best current practice.

A standardized, global approach to the diagnosis and management of IBS may not be feasible, since neither the epidemiology nor the clinical presentation of the condition, nor the availability of diagnostic or therapeutic resources, are sufficiently uniform throughout the world to support the provision of a single, gold standard approach.

This Global WGO Guideline, therefore, includes a set of “cascades” to provide context-sensitive and resource-sensitive options for the diagnosis and management of IBS. The WGO cascades are intended to serve as a “global” complement to, rather than a replacement for, the “gold standard” guidelines produced by regional groups and national societies. With their diagnostic and treatment cascades, WGO guidelines provide a resource-sensitive and context-sensitive approach.

WGO cascades: a hierarchical set of diagnostic, therapeutic, and management options for dealing with risk and disease, ranked by the resources available.

WGO guidelines and cascades are intended to highlight appropriate, context-sensitive and resource-sensitive management options for all geographical areas, regardless of whether they are considered to be “developing,” “semi-developed,” or “developed.” WGO cascades are context-sensitive and the context is not necessarily defined solely by resource availability.

N.B.: The context in which the following cascades were constructed is described in the relevant sections on the diagnosis and management of IBS.

1.1 Cascade options for resource-sensitive IBS diagnosis

High resource levels

Medium resource levels

Low resource levels

* N.B.: Even in “wealthy” countries, not all patients need colonoscopy, which should be reserved in particular for those with alarm symptoms or signs and those over the age of 50. The need for investigations and for sigmoidoscopy and colonoscopy, in particular, should also be dictated by the characteristics of the patient (presenting features, age, etc.) and the geographical location (i.e., whether or not in an area of high prevalence for inflammatory bowel disease, celiac disease, colon cancer, or parasitosis). One could argue, for example, that a 21-year-old woman with symptoms of IBS with diarrhea and no alarm features merits, at most, celiac serology and thyroid evaluation (where appropriate). In general, the diagnosis is “safer” in patients with constipation, whereas in patients with severe diarrhea, there is a greater need to consider tests to exclude organic pathology.

1.2 Cascade options for resource-sensitive IBS management

High resource levels

Medium resources

Low resources

2. Introduction

Irritable bowel syndrome is a relapsing functional bowel disorder defined by symptom-based diagnostic criteria, in the absence of detectable organic causes. The symptomatic array is not specific for IBS, as such symptoms may be experienced occasionally by almost every individual. To distinguish IBS from transient gut symptoms, experts have underscored the chronic and relapsing nature of IBS and have proposed diagnostic criteria based on the occurrence rate of symptoms and their duration.

Definition. Irritable bowel syndrome (IBS) is a functional bowel disorder in which abdominal pain or discomfort is associated with defecation and/or a change in bowel habit. Sensations of discomfort (bloating), distension, and disordered defecation are commonly associated features. In some languages, the words “bloating” and “distension” may be represented by the same term.

Some characteristics of IBS are:

2.1 IBS subclassification

According to the Rome III criteria, IBS may be subtyped or subclassified on the basis of the patient’s stool characteristics, as defined by the Bristol Stool Scale:

It must be remembered, however, that:

On clinical grounds, other sub-classifications may be developed:

However, with the exception of PI-IBS, which is quite well characterized, the relevance of any of these other classifications to the prognosis or response to therapy in patients with IBS remains to be defined.

It must also be remembered that the Rome III criteria are not commonly used in clinical practice. Furthermore, cultural issues may inform symptom reporting. In India, for example, a patient who reports straining or passing hard stools (often with a feeling of incomplete evacuation) is likely to complain of constipation even if he or she passes stools more than once daily.

There is considerable overlap and a tendency to transition between IBS-C and functional constipation.

2.2 Global prevalence and incidence

The global picture of the prevalence of IBS is far from complete, as no data are available from several regions. In addition, comparisons of data from different regions are often problematic due to the use of different diagnostic criteria (in general, the “looser” the criteria, the higher the prevalence), as well as the influence of other factors such as population selection, the inclusion or exclusion of comorbid disorders (e.g., anxiety), access to health care, and cultural influences. In Mexico, for example, the prevalence of IBS in the general population, measured using the Rome II criteria, was 16%, but the figure increased to 35% among individuals in a university-based community. What is remarkable is that the available data suggest that the prevalence is quite similar across many countries, despite substantial lifestyle differences.

2.3 Other observations on IBS epidemiology

2.4 IBS demographics, East–West differences in presenting features

3. Diagnosis of IBS

3.1 Clinical history

Although it is currently described as a single coherent entity, it is most likely that the disorder termed “IBS” comprises a number of discrete pathophysiological entities, which have not as yet been defined. Thus, a number of pathological processes that we now recognize as quite distinct entities (microscopic colitis, carbohydrate intolerance, and bile acid malabsorption, for example) would formerly have been included within IBS.

In assessing the patient with IBS, it is important not only to consider the primary presenting symptoms, but also to identify precipitating factors and other associated gastrointestinal and extragastrointestinal symptoms. It is vital also to seek out and directly question for the presence of alarm symptoms and to consider, in the relevant context, other explanations for the patient’s symptoms (e.g., bile acid diarrhea, carbohydrate intolerance, microscopic colitis). Thus, the history is critical and involves both the identification of those features regarded as typical of IBS and also the recognition of “red flags,” or other features that suggest alternative diagnoses. Accordingly, the patient should be asked about the following (features marked with an asterisk* are compatible with IBS):

The pattern of abdominal pain or discomfort:

Other abdominal symptoms:

N.B.: Distension can be measured; bloating is a subjective feeling. As defined in English, bloating and distension may not share the same pathophysiology and should not be regarded as equivalent and interchangeable terms, although in other languages they may be represented by a single word, or there may be no expression for bloating, as in Spanish. Nor does either necessarily imply that intestinal gas production is increased.

Nature of the associated bowel disturbance:

Abnormalities of defecation:

Other information from the patient’s history and important warning signs:

3.2 Psychological assessment

Psychological factors have not been shown to cause or influence the onset of IBS. IBS is not a psychiatric or psychological disorder. However, psychological factors may:

For these reasons, coexisting psychological conditions are common in referral centers and may include:

The following may be useful in providing an objective assessment of psychological features:

3.3 Physical examination

3.4 IBS diagnostic algorithm

Fig. 1 Algorithm for diagnosing irritable bowel syndrome (IBS).

4. Evaluation of IBS

A diagnosis of IBS is usually suspected on the basis of the patient’s history and physical examination, without additional tests. Confirmation of the diagnosis of IBS requires the confident exclusion of organic disease in a manner dictated by an individual patient’s presenting features and characteristics. In many instances (e.g., in young patients with no alarm features), a secure diagnosis can be made on clinical grounds alone.

There is a lack of robust evidence and prospective studies regarding the appropriate use of radiological imaging in patients with IBS-like symptoms [5].

4.1 Diagnostic criteria (Rome III)

Table 1 Rome III criteria for diagnosing IBS

A systematic review (2012) of the diagnostic criteria for IBS demonstrated low validity and utilization of the Rome III criteria, and suggested that the Manning criteria were more widely validated and may be more clinically applicable [6]. It is now 24 years since the first Rome meeting, and there have been several changes to the Rome criteria defining IBS. The upcoming Rome IV version should become available in 2016.

In clinical practice, whether in the setting of primary or specialist care, clinicians usually base a diagnosis of IBS on their evaluation of the whole patient (often over time) and consider a multiplicity of features that support the diagnosis (apart from pain and discomfort associated with defecation, or change in stool frequency or form).

Symptoms common in IBS and supportive of the diagnosis:

Behavioral features helpful in recognizing IBS in general practice:

Noncolonic complaints that often accompany IBS:

Associated non-gastrointestinal symptoms:

4.2 Additional tests or investigations

In the majority of cases of IBS, no additional tests or investigations are required. An effort to keep investigations to a minimum is recommended in straightforward cases of IBS, and especially in younger individuals.

Additional tests or investigations should be considered if warning signs (“red flags”) are present:

The following tests (although commonly performed) are indicated only if supported by the clinical history and where locally relevant:

Additional tests or investigations may also be considered if:

4.3 Differential diagnosis

Bile acid malabsorption

Celiac disease

Main symptoms and/or findings:

N.B.: Many patients with celiac disease do not have classical features and may present with “IBS-type” symptoms, including bloating and constipation, along with iron deficiency. A low threshold for investigation should therefore be maintained in high-prevalence regions (those with a prevalence > 1% in the general population).

Lactose intolerance

Main symptoms and/or findings:

In countries with a high prevalence of lactase deficiency, inappropriately labeling IBS patients as lactose-intolerant should be avoided, unless they are consuming substantial amounts of milk and/or milk products, as this could deprive the community of a cheap nutritious source of protein and nutrition in countries such as India. In all parts of the world, the prevalence of lactose malabsorption on breath tests has been consistently similar between IBS and non-IBS subjects.

Inflammatory bowel disease (Crohn’s disease, ulcerative colitis)

Main symptoms and/or findings:

Colorectal carcinoma

Main symptoms and/or findings:

Microcytic (lymphocytic and collagenous) colitis

Acute or chronic diarrhea due to protozoa or bacteria

Main symptoms and/or findings:

A review [11] on the role of intestinal protozoa in IBS concluded that there was “a possible role for protozoan parasites, such as Blastocystis hominis and _Dientamoeba fragilis_” in the etiology of IBS.

While stool testing for Giardia and Amoeba is recommended in India, self-medication with imidazoles is common, rendering the results difficult to interpret.

N.B.: It is essential that all patients with IBS in relevant areas should undergo parasitological investigations in order to rule out the presence of protozoan parasites. It is equally important that these tests are appropriately interpreted and that overtreatment is avoided.

Small-intestinal bacterial overgrowth (SIBO)

Tropical sprue

Diverticulitis

The relationship between IBS and so-called “painful diverticular disease” is unclear; is painful diverticular disease no more than IBS in a patient who has diverticula? In diverticulitis, the classical symptoms and/or findings are episodic and acute to subacute during an episode, featuring:

However, it is now evident that afflicted patients may have more chronic symptoms in between discrete episodes/attacks, and that left-sided and bilateral, but not right-sided diverticular disease, may increase the risk for IBS [15].

Endometriosis

Main symptoms and/or findings:

Pelvic inflammatory disease

Main symptoms and/or findings:

Ovarian cancer

In women over the age of 40, ovarian cancer should be considered in the differential diagnosis. In one survey, the following symptoms were more common among women with ovarian cancer:

The combination of bloating, increased abdominal girth, and urinary symptoms was found in 43% of women with ovarian cancer, but in only 8% of a control population.

Other considerations for the differential checklist

4.4 Comorbidity with other diseases

Patients with overlap syndromes tend to have more severe IBS.

In a meta-analysis, the prevalence of biopsy-proven celiac disease was found to be more than four times higher in patients who met the diagnostic criteria for IBS than in control individuals without IBS [16].

There is a significantly higher prevalence of chronic idiopathic constipation (CIC) in patients with IBS. Distinguishing between IBS-C and CIC may be difficult in clinical practice; several recent studies have called into question the appropriateness and feasibility of creating what appears to be an artificial division between these two functional gastrointestinal disorders [17].

The prevalence of gastroesophageal reflux-type symptoms in patients with IBS is four times higher than in those without IBS. There is an overlap between the two conditions in up to 25% of individuals. It is recommended that when physicians encounter patients with symptoms of IBS, they should routinely screen for coexistent gastroesophageal reflux symptoms [18].

Symptoms compatible with IBS have been reported to be significantly higher in patients with inflammatory bowel disease (IBD) in comparison with non-IBD controls, even among those thought to be in remission. IBS-type symptoms were also found to be significantly more common in patients with Crohn’s disease (CD) than in those with ulcerative colitis (UC), and in those with active disease [19]. Of course, a diagnosis of IBS would not be appropriate in a patient with active IBD.

5. Management of IBS

5.1 Introduction

Figure 2 provides a general outline of a management scheme for patients presenting with IBS-type symptoms.

Fig. 2 Management of patients with symptoms of irritable bowel syndrome.

Given that there is no general agreement on the cause of IBS, it comes as no surprise that no single treatment is currently regarded throughout the world as being universally applicable to the management of all IBS patients.

Given also the common association between IBS symptoms and such factors as diet, stress, and psychological factors, attention should be given to adopting measures that may alleviate, if not eliminate, such precipitants. Dietary differences between different countries and ethnic groups would be expected to have a significant influence on the prevalence of symptoms of IBS, but little information is available.

Recent data on disturbances in the intestinal flora (microbiota) in IBS, as well as the suggestion mentioned above (albeit a controversial one) that SIBO may be a factor, have spurred interest in novel approaches: probiotics, prebiotics, and antibiotics. Recent meta-analyses confirm a role for probiotics in IBS, but also make it clear that the effects of probiotics in IBS, as elsewhere, are highly strain-specific. Variability and the formulation of specific strains vary dramatically around the world. For example, Bifidobacterium infantis 35624, which currently has the best evidence base for efficacy in IBS, is at present available only in the United States, Canada, the United Kingdom, and Ireland. Issues of quality control also continue to complicate recommendations in this area.

IBS patients commonly have recourse to a variety of alternative/complementary therapies throughout the world. In India (in Ayurvedic medicine) and China, for example, herbal remedies are widely available and commonly used for IBS. However, their efficacy is difficult to assess, as the concentrations of active ingredients vary considerably depending on the extraction process. Few “alternative” therapies have been subjected to the rigors of a randomized trial in IBS.

A recent systematic review, although noting limitations related to trial design in many instances, provided evidence to support the use of antidepressants (both tricyclic antidepressants and selective serotonin reuptake inhibitors, SSRIs) in IBS.

Nonpharmacological factors are often ignored, but are of paramount importance in the management of IBS. The physician–patient relationship is critical and should include attention to the following, both during the initial assessment and in the subsequent follow-up:

5.2 Diet

Specialized diets may improve symptoms in some IBS patients [20].

Fibers

Probiotics

Some probiotics provide global relief of symptoms in IBS, and others alleviate individual symptoms such as bloating and flatulence [20,22]. However, the duration of these benefits and the nature of the most effective species are not clear [23]. The efficacy of probiotics is difficult to interpret, as different strains, doses, formulations, and methods of delivery have been used in various studies [21]. Furthermore, most randomized controlled studies of probiotics in IBS have been of short duration, have not used an appropriate study design, and have not adequately reported adverse events [22].

There is at present insufficient evidence for a general recommendation of prebiotics or synbiotics in patients with IBS [20]. A recent consensus statement provides guidance on the use of specific probiotics in the management of IBS [24].

5.3 Drug therapy

A variety of agents are used throughout the world for the treatment of individual symptoms in IBS, as follows:

It is important to note that the range of agents available and their formulations vary considerably between countries, and it is imperative that the prescribing physician be knowledgeable regarding the efficacy and risk profile of any agent that he or she is about to prescribe, rather than extrapolating from evidence derived from other agents in the same class or agents that have similar modes of action.

Overall symptoms—first-line therapy

Overall symptoms—second-line therapy

Overall symptoms—other therapeutic options

Specific symptoms—pain

Specific symptoms—constipation

Specific symptoms—diarrhea

Specific symptoms—bloating and distension

5.4 Psychological and other treatments

General nonpharmacological recommendations

Psychological interventions

Apart from the general approaches described above for governing the conduct of the doctor–patient relationship in IBS, more formal psychological interventions may be contemplated in certain circumstances and depending on the availability of appropriate resources and expertise. Such approaches may include:

The American College of Gastroenterology (ACG) Task Force [37] concluded that psychological therapies, including cognitive therapy, dynamic psychotherapy, and hypnotherapy, but not relaxation therapy, are more effective than usual care in relieving the global symptoms of IBS. However, Ford et al. [20] found that the quality of evidence was very low and that the results were only slightly superior to usual care or waiting-list control. With the exception of a single study, these therapies have not been shown to be superior to placebo. The sustainability of their effect is questionable.

With regard to herbal therapies and acupuncture, the ACG Task Force concluded that the available randomized controlled trials, mostly testing unique Chinese herbal mixtures, appeared to show a benefit. It was not possible to combine these studies into a meaningful meta-analysis, however, and overall, any benefit of Chinese herbal therapy in IBS continues to be potentially confounded by the variable components used and their purity. Also, there are significant concerns about toxicity, especially liver failure, with the use of any Chinese herbal mixture. A systematic review of trials of acupuncture was inconclusive due to heterogeneous outcomes. Further research is needed before any recommendations on acupuncture or herbal therapy can be made.

5.5 Prognosis

For most patients with IBS, symptoms are likely to persist, but not worsen. Symptoms will deteriorate in a smaller proportion, and some patients will recover completely.

Factors that may negatively affect the prognosis include:

Approaches by the physician that positively affect the treatment outcome:

5.6 Follow-up

In mild cases, there is generally no medical need for follow-up consultations in the long term, unless:

6. Appendix: useful resources

References

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