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Background: Little is known about the natural history and impact of irritable bowel syndrome (IBS)-type symptoms on psychological health and quality of life in inflammatory bowel disease (IBD). We aimed to address this in a 12-month longitudinal follow-up study of secondary care patients., Methods: We collected demographic, Rome III IBS-type symptom, psychological, and quality of life data, with questionnaires at 3-month intervals, over 12 months of follow-up in patients with IBD in clinical remission at baseline. We assessed the natural history of Rome III IBS-type symptoms over the 12 months of the study and compared psychological and quality of life data between those reporting Rome III IBS-type symptoms at each of the points of follow-up with those not reporting such symptoms., Key Results: Among 206 patients with IBD in clinical remission at baseline (104 [50.5%] women, mean age 56.9 years [range 18-83 years], 79 [38.3%] Crohn's disease), 33 (16.0%) reported Rome III IBS-type symptoms at baseline and 72 (35.0%) reported Rome III IBS-type symptoms at one or more time points. Among the 33 patients with Rome III IBS-type symptoms at baseline, symptoms resolved in 6 (18.2%) patients, were present throughout in 6 (18.2%) patients, and fluctuated in the remaining 21 (63.6%) patients. Among the 39 patients with new onset of Rome III IBS-type symptoms after baseline, 24 (65.1%) had symptoms at one point in time only, 10 (25.6%) at two points, four (10.3%) at three points, and one (2.6%) at four points. At each point in time, reporting IBS-type symptoms was associated with significantly higher anxiety, depression, or somatoform symptom-reporting scores, and/or lower quality of life scores., Conclusions & Inferences: In this 12-month follow-up study, one-third of patients with IBD reported presence of Rome III IBS-type symptoms at any point in time. Reporting such symptoms was associated with significant impacts on psychological health and/or quality of life., (© 2023 The Authors. Neurogastroenterology & Motility published by John Wiley & Sons Ltd.)

Background & Aims: Irritable bowel syndrome (IBS) is a positive diagnosis, made using symptom-based criteria and limited, judicious, investigation. However, this may lead to uncertainty on the part of clinicians regarding potential for a missed diagnosis of organic gastrointestinal disease. Few studies have examined durability of a diagnosis of IBS, and none have used the current gold standard to diagnose IBS, the Rome IV criteria., Methods: We collected complete symptom data from 373 well-characterized adults meeting Rome IV criteria for IBS referred to a single UK clinic between September 2016 and March 2020. All patients underwent relatively standardized work-up to exclude relevant organic disease before diagnosis. We followed these individuals up to December 2022, assessing rates of rereferral, reinvestigation, and missed organic gastrointestinal disease., Results: During a mean follow-up of 4.2 years per patient (total follow-up in all patients, 1565 years), 62 (16.6%) patients were rereferred. Of these, 35 (56.5%) were rereferred for IBS and 27 (43.5%) for other gastrointestinal symptoms. Among the 35 rereferred with IBS this was caused by a change in symptoms in only 5 (14.3%). Reinvestigation was undertaken in 21 (60.0%) of 35 rereferred with IBS and 22 (81.5%) of 27 rereferred with other symptoms (P = .12). Only 4 (9.3% of those reinvestigated and 1.1% of the entire cohort) new cases of relevant organic disease, which may have been responsible for IBS symptoms at baseline, were identified (1 case of chronic calcific pancreatitis among those rereferred with IBS and 1 case each of inflammatory bowel disease-unclassified, moderate bile acid diarrhea, and small bowel obstruction among those rereferred with other gastrointestinal symptoms)., Conclusions: Despite rereferral for gastrointestinal symptoms among 1 in 6 patients overall, with almost 10% rereferred with ongoing IBS symptoms, and substantial reinvestigation rates, missed organic gastrointestinal disease occurred in only 1%. A diagnosis of Rome IV IBS after limited investigation is safe and durable., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: The long-term natural history and impact of irritable bowel syndrome (IBS)-type symptoms on outcomes in inflammatory bowel disease (IBD) are uncertain., Aim: To assess this in a longitudinal follow-up study of patients in secondary care METHODS: We assessed the natural history of IBS-type symptoms in IBD via Rome III criteria applied at baseline, and 2 and 6 years. We defined longitudinal disease activity as the need for glucocorticosteroids or flare, escalation, hospitalisation or intestinal resection. To assess healthcare utilisation, we recorded the number of outpatient clinic attendances and investigations. We also collected anxiety, depression and somatoform symptom scores and quality of life scores during follow-up., Results: Among 125 individuals with Rome III data at all three time points, only 41 (32.8%) never reported IBS-type symptoms. Fifteen patients (12.0%) had IBS-type symptoms at baseline that resolved, 19 (15.2%) had fluctuating symptoms, 35 (28.0%) had new-onset symptoms, and 15 (12.0%) had persistent symptoms. Among more than 300 patients with IBD activity data, IBS-type symptoms were not associated with an increased likelihood of the need for glucocorticosteroids or flare, escalation, hospitalisation or intestinal resection. However, the mean numbers of outpatient appointments and endoscopic investigations were significantly higher among those with IBS-type symptoms. Anxiety, depression and somatoform symptom scores were significantly higher, and quality of life scores were significantly lower, in those reporting IBS-type symptoms at least once during the study., Conclusions: IBS-type symptoms affected more than two-thirds of patients with IBD during >6 years of follow-up and were associated with increased healthcare utilisation, and worse anxiety, depression, somatoform symptom and quality of life scores, but not adverse disease activity outcomes., (© 2022 John Wiley & Sons Ltd.)

Introduction: Little is known about the differences between patients diagnosed with irritable bowel syndrome (IBS) by a physician who meet the Rome IV criteria for IBS and those who do not. We conducted a longitudinal follow-up study examining this., Methods: We collected complete gastrointestinal, extraintestinal, and psychological symptom data from 577 consecutive adult patients with suspected IBS in a single UK gastroenterology clinic. We compared baseline characteristics between patients who met Rome IV criteria for IBS, and those who had IBS according to a physician's diagnosis but who did not meet Rome IV criteria, as well as examining whether meeting Rome IV criteria at baseline influenced evolution of symptoms under therapy., Key Results: Of 455 patients diagnosed with IBS by a physician, 375 (82.4%) met Rome IV criteria and 80 (17.4%) did not. Those who met Rome IV criteria were more likely to report severe symptoms (67.6%, vs. 30.0%, p < 0.001) and that symptoms limited activities ≥50% of the time (63.0%, vs. 37.5%, p < 0.001). Patients with Rome IV IBS were more likely to have abnormal anxiety scores (50.8%, vs. 35.9%, p = 0.007) and higher levels of somatoform symptom-reporting (29.4%, vs. 12.5%, p < 0.001). Despite this, during longitudinal follow-up, there was no significant difference in mean number of appointments required subsequently, or IBS symptom severity., Conclusions and Inferences: Although patients who met the Rome IV criteria had more severe symptoms at baseline and were more likely to exhibit psychological comorbidity, they did not appear to have a worse prognosis than those with physician-diagnosed IBS., (© 2021 John Wiley & Sons Ltd.)

Background: Irritable bowel syndrome (IBS)-type symptoms are common in inflammatory bowel disease (IBD), but few studies have examined the prevalence and impact of IBS-type symptoms in IBD according to Rome IV criteria., Methods: We collected demographic, symptom (Rome III, Rome IV, and clinical disease activity indices), psychological (anxiety, depression, and somatization), and quality of life data from 973 IBD patients. Medical records were reviewed to document disease type, extent/location, behavior, medical therapy, and antidepressant or opioid use. We compared characteristics of individuals with no IBS-type symptoms, Rome III IBS-type symptoms, and Rome IV IBS-type symptoms., Key Results: In total, 302 (31.0%) patients met the Rome III criteria for IBS, and 172 (17.7%) met Rome IV criteria. Those with IBS-type symptoms were younger, more likely to be female, and had higher rates of antidepressant (p = 0.006) or opioid use (p = 0.001). Rome IV IBS-type symptoms were associated with symptoms of mood disorders, flare of disease activity, and lower quality of life scores (p < 0.001 for all analyses). Compared with Rome III criteria, those with Rome IV IBS-type symptoms had significantly higher rates of anxiety (p < 0.001), depression (p = 0.002), and somatization (p < 0.001), lower quality of life scores (p < 0.001) and were more likely to have CD (p = 0.011), with ileal distribution (p = 0.006)., Conclusions and Inferences: Rome IV IBS-type symptoms are associated with increased psychological co-morbidity, lower quality of life scores, and higher rates of antidepressant or opioid use. This is a cohort potentially at risk of adverse clinical outcomes and should be a focus for future research., (© 2021 John Wiley & Sons Ltd.)

Objectives: Despite being proposed 4 years ago, there has been no independent validation study of the Rome IV criteria for IBS. We assessed their performance for the diagnosis of IBS in secondary care and compared them with the previous iteration, the Rome III criteria., Design: We collected complete symptom data from consecutive adult patients with suspected IBS referred to a single UK clinic. All subjects underwent relatively standardised workup, with assessors blinded to symptom status. The reference standard used to confirm IBS was the presence of lower abdominal pain or discomfort in association with altered stool form or frequency, in a patient with no evidence of organic gastrointestinal disease after investigation. Sensitivity, specificity and positive and negative likelihood ratios (LRs), with 95% CIs, were calculated for each of the diagnostic criteria., Results: The level of agreement between the Rome IV and Rome III criteria was good (kappa=0.65). Compared with the reference standard, sensitivity and specificity of the Rome IV criteria in 572 patients (431 (75.3%) women, mean age 36.5 years) were 82.4% and 82.9%, respectively. Positive and negative LRs for the Rome IV criteria were 4.82 (95% CI 3.30 to 7.28) and 0.21 (95% CI 0.17 to 0.26), respectively. The Rome IV criteria performed best in those with IBS with constipation or mixed bowel habits. In 471 patients (350 (74.3%) women, mean age 36.7 years), compared with the reference standard, the sensitivity and specificity of the Rome III criteria were 85.8% and 65.0%; positive and negative LRs were 2.45 (95% CI 1.90 to 3.27) and 0.22 (0.16 to 0.29), respectively. Incorporating mood and extraintestinal symptom reporting into diagnostic criteria did not improve their performance significantly., Conclusions: The Rome IV criteria performed significantly better than the Rome III criteria in diagnosing IBS in this single centre secondary care study, although the clinical relevance of this is uncertain., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Patients with inflammatory bowel disease (IBD) often report symptoms compatible with irritable bowel syndrome (IBS), which might have an effect on psychological health. However, previous estimates of the magnitude of this issue have not accounted for ongoing inflammation as the potential cause. We updated a previous systematic review and meta-analysis to determine prevalence of IBS-type symptoms in patients with IBD in remission to better quantify the magnitude of this issue., Methods: In this systematic review and meta-analysis, Embase, Embase Classic, and MEDLINE were searched (from Jan 1, 2012, to May 11, 2020) to identify prospective case-control or cross-sectional studies reporting prevalence of symptoms meeting diagnostic criteria for IBS in adults with IBD in remission. Studies were required to have recruited an unselected adult population (more than 90% of participants aged ≥16 years) with histologically or radiologically confirmed IBD and include at least 50 participants. Pooled prevalence and odds ratios (ORs) with 95% CIs were calculated according to the definition of remission, criteria used to define IBS-type symptoms, and type of IBD. The association between IBS-type symptom reporting and psychological comorbidity was examined using weighted mean difference (WMD) or standardised mean difference (SMD) in anxiety and depression scores between those reporting IBS-type symptoms and those not, for cases in which these data were available., Findings: Of 3370 studies identified, 27 were eligible, of which 18 were newly identified. Among 3169 patients with IBD in remission, pooled prevalence of IBS-type symptoms was 32·5% (95% CI 27·4-37·9; I 2 =90·1%). Prevalence was lower when remission was defined by endoscopic assessment (23·5%, 95% CI 17·9-29·6; I 2 =59·9%) or histological assessment (25.8%, 95% CI 20.2-31.7; I 2 =not applicable) than when defined by validated clinical disease activity index (33·6%, 26·3-41·2; I 2 =91·8%) and higher in Crohn's disease than in ulcerative colitis (36·6%, 29·5-44·0; I 2 =82·9% vs 28·7%, 22·9-34·8; I 2 =87·2%). Anxiety (WMD 2·5; 95% CI 0·8-4·3) and depression (SMD 0·64; 0·44-0·84) scores were significantly higher among those who reported IBS-type symptoms than in those who did not., Interpretation: Prevalence of symptoms compatible with IBS in patients with IBD varied according to how remission was defined. However, even when stringent criteria such as endoscopic or histological remission were used, about a quarter of patients reported these symptoms. Such symptoms were more common in patients with Crohn's disease and were associated with psychological comorbidity. Addressing psychological wellbeing might improve outcomes in this specific group of patients., Funding: None., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: The microbiome is implicated in the pathogenesis of inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS). Whether a distinct microbiome profile is associated with the reporting of IBS-type symptoms in IBD patients is uncertain. We aimed to resolve this issue using a cross-sectional study design., Methods: Using clinical disease activity indices, the Rome III criteria for IBS and fecal calprotectin levels, we divided IBD patients into 4 groups: IBS-type symptoms, quiescent disease, occult inflammation, and active disease. A16S rRNA microbiome analysis was performed to determine whether any taxa were differentially abundant, and whether there were any differences in alpha or beta diversity in patients reporting IBS-type symptoms compared with those in the other 3 groups., Results: Of 270 patients included, 70 (25.9%) had IBS-type symptoms, 81 (30.0%) quiescent IBD, 66 (24.4%) occult inflammation, and 53 (19.6%) active IBD. At phylum level, there was a nonsignificant increase in the abundance of Actinobacteria in patients reporting IBS-type symptoms, but no other differences at any taxonomic level. When compared with patients reporting IBS-type symptoms, mean alpha diversity was greater in patients with quiescent disease, although this was nonsignificant (28.6 vs 31.7, P = 0.33), and similar to those with occult inflammation and active disease. Beta diversity variation among the 4 groups was significant for unweighted (P = 0.002) but not weighted (P = 0.21) UniFrac analysis., Conclusions: Reporting IBS-type symptoms was not associated with distinct microbiome alterations. Unmeasured confounding could have impacted the significance of our findings.

Objectives: The impact of irritable bowel syndrome (IBS)-type symptoms on the natural history of inflammatory bowel disease (IBD) is uncertain. We aimed to address this in a longitudinal study of secondary care patients., Methods: Longitudinal disease activity was defined by disease flare, escalation of medical therapy, hospitalization, or intestinal resection. The number of investigations performed and clinics attended determined healthcare utilization. Psychological well-being and quality of life were assessed using validated questionnaires. These outcomes were compared over a minimum period of 2 years between patients reporting IBS-type symptoms and patients with quiescent disease, occult inflammation, and active disease at baseline., Results: In 360 IBD patients, there were no differences in longitudinal disease activity between patients with IBS-type symptoms and patients with quiescent disease or occult inflammation. Disease flare and escalation of medical therapy was more common in patients with active disease than in patients with IBS-type symptoms (hazard ratio (HR) = 3.16; 95% confidence interval (CI) 1.93-5.19 and HR = 3.24; 95% CI 1.98-5.31, respectively). A greater number of investigations were performed in patients with IBS-type symptoms than quiescent disease (P = 0.008), but not compared with patients with occult inflammation or active disease. Anxiety, depression, and somatization scores at follow up were higher, and quality-of-life scores lower, in patients with IBS-type symptoms when compared with patients with quiescent disease, but were similar to patients with active disease., Conclusions: IBS-type symptoms in IBD were associated with increased healthcare utilization, psychological comorbidity, reduced quality of life, but not adverse disease activity outcomes during extended follow-up.

Background & Aims: Symptoms compatible with irritable bowel syndrome (IBS) are common in patients with inflammatory bowel disease (IBD), but it is unclear whether this relates to occult IBD activity. We attempted to resolve this issue in a secondary care population by using a cross-sectional study design., Methods: We analyzed Rome III IBS symptoms, disease activity indices, and psychological, somatization, and quality of life data from 378 consecutive, unselected adult patients with IBD seen in clinics at St James's University Hospital in Leeds, United Kingdom from November 2012 through June 2015. Participants provided a stool sample for fecal calprotectin (FC) analysis; levels ≥250 μg/g were used to define mucosal inflammation. By using symptom data and FC levels we identified 4 distinct groups of patients: those with true IBS-type symptoms (IBS-type symptoms with FC levels <250 μg/g, regardless of disease activity indices), quiescent IBD (no IBS-type symptoms with FC levels <250 μg/g, regardless of disease activity indices), occult inflammation (normal disease activity indices and FC levels ≥250 μg/g, regardless of IBS symptom status), or active IBD (abnormal disease activity indices with FC levels ≥250 μg/g, regardless of IBS symptom status). We compared characteristics between these groups., Results: Fifty-seven of 206 patients with Crohn's disease (27.7%) and 34 of 172 patients with ulcerative colitis (19.8%) had true IBS-type symptoms. Levels of psychological comorbidity and somatization were significantly higher among patients with true IBS-type symptoms than patients with quiescent IBD or occult inflammation. Quality of life levels were also significantly reduced compared with patients with quiescent disease or occult inflammation and were similar to those of patients with active IBD. By using FC levels ≥100 μg/g to define mucosal inflammation, we found a similar effect of IBS-type symptoms on psychological health and quality of life., Conclusions: In a cross-sectional study, we identified a distinct group of patients with IBD and genuine IBS-type symptoms in the absence of mucosal inflammation. These symptoms had negative effects on psychological well-being and quality of life to the same degree as active IBD. New management strategies are required for this patient group., (Copyright © 2017 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: The accuracy of symptom-based diagnostic criteria for irritable bowel syndrome (IBS) is modest., Aims: To derive and validate a new test that utilises latent class analysis., Methods: Symptom, colonoscopy, and histology data were collected from 1981 patients and 360 patients in two cohorts referred to secondary care for investigation of their gastrointestinal symptoms in Canada and the UK, respectively. Latent class analysis was used to identify naturally occurring clusters in patient-reported symptoms in the Canadian dataset, and the latent class model derived from this was then applied to the UK dataset in order to validate it. Sensitivity, specificity, and positive and negative likelihood ratios (LRs) were calculated for the latent class models., Results: In the Canadian cohort, the model had a sensitivity of 44.7% (95% CI 40.0-50.0) and a specificity of 85.3% (95% CI 83.4-87.0). Positive and negative LRs were 3.03 (95% CI 2.57-3.56) and 0.65 (95% CI 0.59-0.71) respectively. A maximum positive LR of 3.93 was achieved following construction of a receiver operating characteristic curve. The performance in the UK cohort was similar, with a sensitivity and specificity of 52.5% (95% CI 42.2-62.7) and 84.3% (95% CI 79.3-88.6), respectively. Positive and negative LRs were 3.35 (95% CI 2.38-4.70) and 0.56 (95% CI 0.45-0.68), respectively, with a maximum positive LR of 4.15., Conclusions: A diagnostic test for IBS, utilising patient-reported symptoms incorporated into a latent class model, performs as accurately as symptom-based criteria. It has potential for improvement via addition of clinical markers, such as coeliac serology and faecal calprotectin., (© 2017 John Wiley & Sons Ltd.)

Objectives: Symptom-based criteria to diagnose irritable bowel syndrome (IBS) positively perform only modestly. Our aim was to assess whether including other items from the clinical history and limited diagnostic evaluation improves their performance., Methods: We collected complete symptom, colonoscopy, and histology data from 318 consecutive, unselected adult patients with lower gastrointestinal (GI) symptoms in secondary care. All participants underwent colonoscopy, with relevant organic findings recorded. The reference standard used to define the presence of true IBS was patient-reported lower abdominal pain or discomfort associated with a change in bowel habit, in the absence of organic GI disease. Sensitivity, specificity, and positive and negative likelihood ratios (LRs), with 95% confidence intervals, were calculated for Rome III criteria, as well as for modifications, incorporating nocturnal stools, results of simple blood tests (hemoglobin and C-reactive protein (CRP)), measures of somatization, and/or affective disorders (hospital anxiety or depression scale (HADS) score)., Results: The sensitivity and specificity of the Rome III criteria for identifying IBS was 69.6%, and 82.0%, respectively, with positive and negative LRs of 3.87 and 0.37, respectively. Clinically useful enhancements in positive LRs were provided by combining Rome III criteria with: (a) high level of somatization (7.27); (b) normal hemoglobin and CRP with HADS score of ≥8 (5.04); (c) normal hemoglobin and CRP with a high level of somatization (7.56); or (d) no nocturnal passage of stool with a high level of somatization (17.3). Specificity was ≥95% with each of these modifications., Conclusions: Incorporating nocturnal stools, somatization, and affective disorders from the clinical history, and hemoglobin and CRP measurements, enhances the positive LR and specificity of symptom-based Rome III criteria for IBS.

Purpose of Review: Irritable bowel syndrome (IBS) is a chronic gastrointestinal disorder associated with significant physical and psychological comorbidity. The etiology of the condition is uncertain but recent research suggests that the gut bacterial composition may play a role in its development. Therefore, manipulation of the intestinal microbiome by using probiotics and symbiotics has the potential to improve patient outcomes in IBS., Recent Findings: Numerous randomized controlled trials suggest a benefit of probiotics in the management of IBS, with a significant reduction in the likelihood of symptoms persisting after therapy, and improvements in abdominal pain, bloating and flatulence when probiotics are compared with placebo. Evidence for the effect of probiotics on quality of life is conflicting. Relatively few randomized controlled trials have examined the effect of symbiotics on outcomes in IBS, but results thus far are promising., Summary: Probiotics appear to be beneficial in IBS. Data supporting the use of symbiotics is sparse. Whether symbiotics are superior to probiotics is unclear.

Background: Irritable bowel syndrome (IBS) is a complex, heterogeneous disease which can be challenging to diagnose. No study has identified and assessed the accuracy of all available methods of diagnosing IBS., Aim: To conduct a systematic review of the literature to identify and assess accuracy of symptom-based diagnostic criteria, biomarkers, psychological markers or combinations thereof., Methods: MEDLINE, EMBASE and EMBASE Classic were searched (until April 2015) to identify studies reporting accuracy of available methods to diagnose IBS in adult populations. Eligible studies assessed accuracy of these diagnostic tests against an accepted reference standard. Data were extracted to calculate positive and negative likelihood ratios, with 95% confidence intervals (CIs), of the diagnostic test utilised. Where more than one study used the same test, data were pooled in a meta-analysis., Results: Twenty-two studies (7106 patients) were eligible. Positive and negative likelihood ratios of the current gold standard, the Rome III criteria, were 3.35 (95% CI: 2.97-3.79) and 0.39 (95% CI: 0.34-0.46), similar to other symptom-based criteria. Eleven biomarkers performed no better than symptom-based criteria. Psychological markers performed well in one study. Five different combinations were assessed. The best in terms of positive likelihood ratio was faecal calprotectin, intestinal permeability and Rome I criteria (26.4; 95% CI: 11.4-61.9), and in terms of negative likelihood ratio serum-based biomarkers and psychological markers (0.18; 95% CI: 0.12-0.25)., Conclusions: Symptom-based diagnostic criteria, biomarkers and psychological markers performed modestly in predicting IBS. Combining symptoms with markers appears more effective, and may represent the way forward in the diagnosis of IBS., (© 2015 John Wiley & Sons Ltd.)