IBD with IBS-Like Symptoms (Rome Foundation & IOIBD Joint Consensus): Gastroenterology | May 2026
Introduction
A significant number of patients with inflammatory bowel disease in remission continue to report symptoms such as abdominal pain, bloating, and altered bowel habits. These symptoms often mimic irritable bowel syndrome, creating confusion in clinical practice. Physicians frequently struggle to differentiate between ongoing subclinical inflammation and functional symptoms, leading to variability in management.
This joint consensus from the Rome Foundation and the International Organisation for the Study of IBD provides a structured, evidence-based approach to defining, evaluating, and managing these patients.
Why This Guideline Was Required
The absence of standardised terminology and diagnostic criteria has led to a major clinical problem: patients with quiescent IBD are often misclassified as having active disease, resulting in unnecessary escalation of immunosuppressive or biologic therapies.
At the same time, failure to recognise functional symptoms may delay appropriate therapies such as dietary interventions or brain–gut behavioral treatments. This consensus aims to bridge this gap by clearly separating inflammatory activity from functional symptom burden.
Key Takeaways for Clinicians
- Standard Terminology Is Essential
The preferred term is “IBD with IBS-like symptoms.” This reflects the coexistence of functional symptoms in the absence of active inflammation, avoiding misleading labels such as “IBS in IBD.”
- Definition Requires Exclusion of Active Disease
Symptoms such as abdominal pain, bloating, and altered bowel habits should only be attributed to IBS-like mechanisms after ruling out active inflammation or structural complications.
- Combine Clinical Criteria with Objective Assessment
Diagnosis should integrate Rome criteria for IBS along with objective evidence of remission, including biomarkers, endoscopy, histology, or imaging.
- Do Not Escalate IBD Therapy Based on Symptoms Alone
Symptoms alone are insufficient to justify escalation of biologics or immunosuppressants. Objective confirmation of inflammation is mandatory before changing disease-modifying therapy.
- Biomarkers Play a Central Role
Faecal calprotectin and CRP should be used routinely to assess inflammatory activity and help distinguish functional symptoms from active IBD.
- Endoscopic and Histologic Remission Matter
For research and precision care, deeper remission definitions—including endoscopic and histologic healing—are encouraged to improve diagnostic clarity.
- Consider Overlapping Mechanisms
IBS-like symptoms in IBD may result from visceral hypersensitivity, altered motility, microbiome changes, or central pain processing, rather than inflammation alone.
- Psyllium Can Be First-Line Therapy
Soluble fibre, such as psyllium, is recommended in appropriate patients, provided there is no stricture or obstruction risk.
- Low FODMAP Diet Has a Role
A short-term low FODMAP diet can help reduce bloating and functional symptoms, but long-term restriction should be avoided.
- Use Targeted Pharmacologic Therapy
Selected patients may benefit from antispasmodics, neuromodulators, or gut-directed therapies, tailored to symptom profile.
- Brain–Gut Behavioural Therapies Are Important
Psychological interventions such as cognitive behavioural therapy and gut-directed hypnotherapy are effective and should be integrated into care.
- Multidisciplinary Care Is Ideal
Management often requires collaboration between gastroenterologists, dietitians, and psychologists for optimal outcomes.
- Avoid Over-Investigation
Once adequate exclusion of inflammation is achieved, repeated invasive testing should be minimised unless new red flags emerge.
- Patient Education Is Critical
Patients should be reassured that symptoms do not necessarily indicate disease flare, reducing anxiety and improving adherence.
- Research Definitions Should Be Standardised
The consensus proposes candidate thresholds for remission (endoscopic, histologic, biomarker, imaging) to ensure uniformity in future trials.
- Recognise Heterogeneity
Not all patients behave similarly; management should be individualised based on symptom pattern and disease history.
Practical Clinical Message
This guideline shifts the focus from reflex escalation of IBD therapy to a more nuanced, evidence-based approach that distinguishes inflammation from functional symptoms. It reinforces the importance of objective disease assessment and encourages the use of IBS-directed therapies when appropriate.
For practising gastroenterologists, this represents a major step toward precision medicine in IBD, where treatment is guided not just by symptoms but by underlying pathophysiology.
Conclusion
This first joint Rome Foundation and IOIBD consensus establishes a clear framework for diagnosing and managing IBD with IBS-like symptoms. By emphasising objective assessment, appropriate terminology, and targeted therapies, it aims to reduce overtreatment, improve symptom control, and enhance patient outcomes.
