AGA Clinical Practice Update on Functional Gastrointestinal Symptoms in Patients With Inflammatory Bowel Disease: Expert Review

Abstract

The evidence and best practices summarized in this manuscript are based on relevant scientific publications, systematic reviews, and expert opinion where applicable. Best practice advice 1: A stepwise approach to rule-out ongoing inflammatory activity should be followed in IBD patients with persistent GI symptoms (measurement of fecal calprotectin, endoscopy with biopsy, cross-sectional imaging). Best practice advice 2: In those patients with indeterminate fecal calprotectin levels and mild symptoms, clinicians may consider serial calprotectin monitoring to facilitate anticipatory management. Best practice advice 3: Anatomic abnormalities or structural complications should be considered in patients with obstructive symptoms including abdominal distention, pain, nausea and vomiting, obstipation or constipation. Best practice advice 4: Alternative pathophysiologic mechanisms should be considered and evaluated (small intestinal bacterial overgrowth, bile acid diarrhea, carbohydrate intolerance, chronic pancreatitis) based on predominant symptom patterns. Best practice advice 5: A low FODMAP diet may be offered for management of functional GI symptoms in IBD with careful attention to nutritional adequacy. Best practice advice 6: Psychological therapies (cognitive behavioural therapy, hypnotherapy, mindfulness therapy) should be considered in IBD patients with functional symptoms. Best practice advice 7: Osmotic and stimulant laxative should be offered to IBD patients with chronic constipation. Best practice advice 8: Hypomotility agents or bile-acid sequestrants may be used for chronic diarrhea in quiescent IBD. Best practice advice 9: Antispasmodics, neuropathic-directed agents, and anti-depressants should be used for functional pain in IBD while use of opiates should be avoided. Best practice advice 10: Probiotics may be considered for treatment of functional symptoms in IBD. Best practice advice 11: Pelvic floor therapy should be offered to IBD patients with evidence of an underlying defecatory disorder. Best practice advice 12: Until further evidence is available, fecal microbiota transplant should not be offered for treatment of functional GI symptoms in IBD. Best practice advice 13: Physical exercise should be encourage in IBD patients with functional GI symptoms. Best practice advice 14: Until further evidence is available, complementary and alternative therapies should not be routinely offered for functional symptoms in IBD.

The impact of dietary fermentable carbohydrates on a postinflammatory model of irritable bowel syndrome

“…A low fermentable oligo‐ di‐ mono‐saccharides and polyols (FODMAP) diet is used to reduce symptoms of IBS based on the reduction of poorly absorbed carbohydrates that lead to colonic fermentation and subsequent gas production, abdominal pain, and bloating . While much of the evidence for the use of the low‐FODMAP diet is in patients with IBS, use of the diet has been integrated into clinical practice for management of functional symptoms in IBD …”

“…A small body of evidence from uncontrolled trials suggests the low‐FODMAP diet reduces functional symptoms in IBD and the diet is recommended by some practice guidelines . Despite this, little is known about the effect of the diet on inflammation.…”

“…1 While much of the evidence for the use of the low-FODMAP diet is in patients with IBS, use of the diet has been integrated into clinical practice for management of functional symptoms in IBD. 3 A small body of evidence from uncontrolled trials suggests the low-FODMAP diet reduces functional symptoms in IBD 4 and the diet is recommended by some practice guidelines. 3 Despite this, little is known about the effect of the diet on inflammation.…”

Nutraceuticals as modulators of gut microbiota: Role in therapy

“…Of the aforementioned diets, the low FODMAP diet has gained a significant foothold in the management of irritable bowel syndrome (IBS; Dionne et al, ) and may also be of benefit to some affected by inflammatory bowel disease (Colombel, Shin, & Gibson, ) and celiac disease (Yoosuf, ). Given the prebiotic effects of oligosaccharides (discussed later) on important components of the normal microbiome, such as lactobacilli and bifidobacteria, as well as their metabolic products, such as short‐chain fatty acids (SCFAs), the long‐term effects of the low FODMAP diet were of some concern.…”

“…These contrast with what is often referred to as the "Western diet" which involves high intakes of red meat, processed meat, pre-packaged foods, butter, fried foods, high-fat dairy products, eggs, refined grains, potatoes, corn, corn syrup and high-sugar drinks. The plant-based diets are thought to provide protection against a number of chronic diseases, including cardiovascular disease, through various mechanisms, including the antioxidant effects of plant polyphenols (Pandey & Rizvi, 2009) Of the aforementioned diets, the low FODMAP diet has gained a significant foothold in the management of irritable bowel syndrome (IBS; Dionne et al, 2018) and may also be of benefit to some affected by inflammatory bowel disease (Colombel, Shin, & Gibson, 2019) and celiac disease (Yoosuf, 2019). Given the prebiotic effects of oligosaccharides (discussed later) on important components of the normal microbiome, such as lactobacilli and bifidobacteria, as well as their metabolic products, such as short-chain fatty acids (SCFAs), the longterm effects of the low FODMAP diet were of some concern.…”