A joint Rome Foundation and International Organization for the Study of IBD panel of thirteen experts applied a modified RAND/UCLA appropriateness method to 133 candidate statements, scoring 105 of them across two rounds. Eighty-six were rated appropriate, sixteen uncertain and three inappropriate.
The preferred term is 'IBD with IBS-like symptoms', defined as abdominal pain, bowel habit change or bloating not explained by active inflammation or structural disease. Diagnosis in clinical care should combine Rome criteria with objective exclusion of inflammation — not one or the other. Endorsed treatments are psyllium where there is no stricture, a short-term low-FODMAP diet, targeted drugs and brain-gut behavioural therapies.
The clinical problem this addresses is escalation. A patient in endoscopic remission who reports pain and loose stools is frequently stepped up to a more aggressive biologic, exposed to its risks, and remains symptomatic because the inflammation was never the cause. Requiring objective exclusion of inflammation before attributing symptoms — and requiring it before escalating — is the operative recommendation, and it depends on doing the calprotectin or the endoscopy rather than assuming either way.
- Confirm objective remission before escalating IBD therapy for symptoms
- Use Rome criteria alongside the inflammatory markers, not instead of them
- Offer psyllium where there is no stricture, and a short-term low-FODMAP diet rather than an indefinite one
- Brain-gut behavioural therapy is an endorsed treatment here, not a last resort
- Name the diagnosis to the patient — 'your Crohn's is quiet and this is something else' is a different conversation from 'your tests are normal'
Why it matters
It replaces an unnamed overlap that drives unnecessary biologic escalation with a defined diagnosis that has its own treatments.
Don't overread it
Expert consensus by appropriateness rating — 16 of 105 statements were rated uncertain, and none of this rests on new trial data.
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