Actionability = is there something to do. Prevalence = how much of a general GI practice it touches. Stakes = how consequential the decision is. Evidence strength = how far the study design and the result support the action. Novelty = how likely you are not already doing it.
Motilityrct · n=143 · Aug 18, 2026 · J Gastro Hep · IF 3.5
Clinical takeawayIn IBS-D patients responding to rifaximin, consolidation with 4 weeks of Medilac-S (Bacillus subtilis and Enterococcus faecium) may be considered to reduce relapse risk. Clinicians should note this contradicts current ACG recommendations against probiotics in IBS (conditional, very low evidence against).
What it foundIn IBS-D patients responding to rifaximin, 4-week Medilac-S consolidation therapy reduced relapse from 58% to 40% (p=0.0378) and improved bowel frequency (1.73 vs 2.53 stools/day, p<0.001) and stool consistency (BSFS 4.38 vs 5.15, p<0.001).
ContextRifaximin achieves good initial remission but relapse remains common. This open-label multicenter RCT tested post-rifaximin probiotic consolidation in a specific population (rifaximin-responders). While the 18-point relapse reduction is clinically meaningful, the open-label design and borderline significance (p=0.0378) mean this single trial does not overturn guideline guidance; should involve shared decision-making and explicit discussion that this is an off-guideline approach.
Refinessuggested applicable standard· American College of Gastroenterology, 'ACG Clinical Guideline: Management of Irritable Bowel Syndrome', 2021ShowHide
Decision at stakewhether to recommend probiotics in IBS-D management
…IBS-D: rifaximin (strong, moderate); alosetron only for women with severe IBS-D who have failed conventional therapy (conditional, low); mixed opioid agonists/antagonists, i.e. eluxadoline (conditional, moderate); AGAINST bile acid sequestrants (conditional, very low).
From our summary of this standard, unedited — the part the paper bears on. … marks omitted text. Our wording, not the guideline's; read the source for its own text. The rest of this standard includes IBS-C.
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Diagnosis: use a positive diagnostic strategy based on Rome IV criteria rather than a strategy of exclusion (strong for cost-effectiveness, high quality; consensus for time-to-therapy), and categorize by IBS subtype (consensus). In patients with IBS and diarrhea symptoms: check celiac serology (strong, moderate) and, in those WITHOUT alarm features, fecal calprotectin (or fecal lactoferrin) plus CRP to rule out IBD (strong; moderate quality for CRP/calprotectin, very low for lactoferrin). Recommend AGAINST routine stool testing for enteric pathogens (conditional, low) and AGAINST routine colonoscopy in patients younger than 45 without warning signs (conditional, low). Anorectal physiology testing only when symptoms suggest a pelvic floor disorder and/or for refractory constipation not responding to standard medical therapy (consensus). Treatment, all subtypes: soluble, not insoluble, fiber (strong, moderate); a LIMITED trial of a low-FODMAP diet (conditional, very low); gut-directed psychotherapies for global symptoms (conditional, very low); TCAs for global symptoms (strong, moderate); peppermint suggested (conditional, low); antispasmodics for abdominal pain (conditional, low); AGAINST probiotics (conditional, very low), AGAINST fecal transplant (strong, very low). IBS-C: chloride channel activators (strong, moderate) and guanylate cyclase activators (strong, high); AGAINST PEG products for global IBS-C symptoms (conditional, low); tegaserod reserved for women younger than 65 with ≤1 cardiovascular risk factor who have not adequately responded to secretagogues (strong/conditional, low). IBS-D: rifaximin (strong, moderate); alosetron only for women with severe IBS-D who have failed conventional therapy (conditional, low); mixed opioid agonists/antagonists, i.e. eluxadoline (conditional, moderate); AGAINST bile acid sequestrants (conditional, very low).
Clinical takeawayHeighten clinical recognition that DGBI are prevalent in pediatric populations; systematically assess using Rome V criteria in children with GI symptoms, especially when anxiety, depression, or functional impairment present.
What it foundmultinational epidemiologic data showing 28% of children have DGBI, with peak prevalence at 41% in ages 0-3 and strong association with anxiety, depression and functional impairment
ContextEstablishes first standardized multinational prevalence of paediatric DGBI using Rome V criteria across diverse populations. Demonstrates DGBI affect >1 in 4 children with significant comorbidity and healthcare burden; supports systematic recognition and classification in pediatric care.
Reinforcessuggested applicable standard· Rome Foundation, "Neuromodulators for Functional Gastrointestinal Disorders (Disorders of Gut−Brain Interaction): A Rome Foundation Working Team Report" (Drossman DA, Tack J, Ford AC, Szigethy E, Törnblom H, Van Oudenhove L), Gastroenterology 2018;154(4):1140-1171.e1, 2018ShowHide
Decision at stakewhether to screen for DGBI in pediatric patients with functional gastrointestinal symptoms and or psychiatric comorbidity
…(3) SSRIs are for anxiety, depression and phobic features, not pain: 'SSRIs can be considered in IBS if anxiety states, including hypervigilance, somatic symptom disorder, visceral anxiety, and maladaptive cognitions, are present, and the abdominal pain and diarrhea are not the dominant clinical features.' (4) Functional dyspepsia is treated by Rome IV subgroup.…
From our summary of this standard, unedited — the part the paper bears on. … marks omitted text. Our wording, not the guideline's; read the source for its own text.
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In DGBI where pain is dominant, a central neuromodulator is a logical part of the treatment profile. (1) TCAs are first-line when pain dominates: low-to-modest dosages have the most convincing evidence for chronic GI pain. Start low (10 mg/d helps patients get past early side effects), titrate within 4-6 weeks to 25-75 mg/d at night, and increase further to 100-150 mg/d only if no disturbing side effects develop; evidence for analgesic effect at <25 mg/d is lacking. Tertiary amines (amitriptyline, imipramine) are more anticholinergic/antihistaminic and may be chosen when constipating/sedating effects are useful (IBS-D, disturbed sleep); secondary amines (nortriptyline, desipramine) when those effects are unwanted (IBS-C, or pain with constipation). The TCA class is first-line for IBS, especially IBS-D. (2) SNRIs (duloxetine 30-90 mg, venlafaxine 75-225 mg with >225 mg needed for noradrenergic pain effect, milnacipran) 'may have at least equal benefit as TCAs' for chronic GI pain, but this is extrapolated from fibromyalgia, migraine, widespread body pain and neuropathy; they 'have not been adequately tested for chronic GI pain' and have not been adequately studied in IBS. Their advantage is the absence of anticholinergic/antihistaminic effects that preclude adequate TCA dosing; start in the low-dose range for the first week because nausea is common. SNRIs may be favored for IBS-C. (3) SSRIs are for anxiety, depression and phobic features, not pain: 'SSRIs can be considered in IBS if anxiety states, including hypervigilance, somatic symptom disorder, visceral anxiety, and maladaptive cognitions, are present, and the abdominal pain and diarrhea are not the dominant clinical features.' (4) Functional dyspepsia is treated by Rome IV subgroup. For PDS with early satiety, fullness and nausea predominating: buspirone, dosed as for anxiety, 30 mg/d divided 2-3 times daily, increasable to 60 mg/d (a 4-week trial reduced dyspeptic symptoms). Mirtazapine is 'a good treatment option for PDS when there is chronic nausea and vomiting, or weight loss', 15 mg in the evening for 8 weeks was superior to placebo in FD patients with weight loss and without coexisting anxiety or depression; usual range 15-45 mg in the evening. For EPS, studies mainly support TCAs (amitriptyline), either initially or after an unsuccessful PPI trial; the SNRI group 'can also be considered for patients with EPS who do not tolerate TCA treatment, although confirmatory studies are lacking.' (5) Functional heartburn and functional chest pain (after excluding GERD): 'There is insufficient evidence to recommend a particular class of central agent.' SSRIs have shown some benefit for esophageal pain; low-dose imipramine or amitriptyline 'can be considered,' but those studies are small and one was open-label; venlafaxine 75 mg extended-release at night beat placebo in a young cohort (20-29 years). (6) A comorbid dominant psychiatric diagnosis, identified by clinical assessment or questionnaires such as the HADS, 'may need to be a primary consideration when selecting a neuromodulator'; neuromodulators can alternatively be selected for their peripheral effects (disturbed bowel habit, chronic nausea). (7) Augmentation, reducing the dose of the first agent and adding a second, complementary treatment, is recommended when monotherapy is insufficient or dose-limited by side effects: an azapirone (dyspeptic features, prominent anxiety), a delta ligand (abdominal wall pain, comorbid fibromyalgia; pregabalin 150-600 mg/d, effect expected within a month), an SSRI (dominant anxiety/phobic features), an atypical antipsychotic (quetiapine 25-200 mg for pain with disturbed sleep, the psychiatric range of ≥200-400 mg/d is poorly tolerated; olanzapine/sulpiride for anxiety and nausea), bupropion (prominent fatigue/sleepiness), or a psychological treatment. (8) Behavioral therapy is positioned as an adjunct/augmentation, not as a co-equal mandatory arm: CBT where maladaptive cognitions and catastrophizing are present, DBT/EMDR with a history of PTSD or trauma, hypnosis/mindfulness/relaxation as alternatives; many RCTs support behavioral interventions 'as an adjunct to pharmacologic strategies,' and few studies compare behavioral alone against combination. (9) Continue treatment 6-12 months after treatment response to reduce relapse (empiric recommendation, extrapolated from major depression where 4-9 months is advised); consider longer-term treatment where ongoing psychosocial stress, positive family history, multiple prior episodes, or current psychiatric comorbidity exist. (10) Opioids should be avoided: there are no controlled data supporting opioids in chronic visceral pain, and their use carries substantial risk of opioid-induced constipation and narcotic bowel syndrome. (11) Implementation depends on communication: educate, provide a physiological rationale, address the patient's reluctance to take a 'psychiatric' drug, and involve the patient in medication choice, merely recommending the drug leads to refusal, nonadherence, or anxiety-driven side-effect reports.
Clinical takeawaySystematize IBS-C treatment response assessment using expert consensus domains: before starting treatment, establish baseline severity of the patient's most bothersome symptom(s) and quality-of-life impact; at follow-up, reassess these domains alongside patient satisfaction and side effects to inform shared decision-making on treatment continuation or adjustment. However, no validated standardized measure is yet available; assessment relies on clinical judgment.
What it foundModified Delphi process with US IBS-C experts reached consensus (≥80% agreement) on 14 statements defining treatment-response assessment domains: severity of most bothersome symptoms, impact on health-related quality of life, patient satisfaction with treatment, and side effects. No standardized measure was consistently endorsed by panelists.
ContextAddresses previously undefined best practice in IBS-C management, where treatment-response assessment and adjustment strategies were inconsistent across practices. Formalizes and codifies a patient-centered, multi-domain approach that reflects evolving emphasis on shared decision-making and quality-of-life outcomes in functional GI disorders.
Emergingsuggested applicable standard· American College of Gastroenterology, 'ACG Clinical Guideline: Management of Irritable Bowel Syndrome', 2021ShowHide
Decision at stakehow to systematically assess therapeutic response and guide treatment adjustments in IBS-C
…IBS-C: chloride channel activators (strong, moderate) and guanylate cyclase activators (strong, high); AGAINST PEG products for global IBS-C symptoms (conditional, low); tegaserod reserved for women younger than 65 with ≤1 cardiovascular risk factor who have not adequately responded to secretagogues (strong/conditional, low).…
From our summary of this standard, unedited — the part the paper bears on. … marks omitted text. Our wording, not the guideline's; read the source for its own text. The rest of this standard includes IBS-D.
Our full summary of this standardShowHide
Diagnosis: use a positive diagnostic strategy based on Rome IV criteria rather than a strategy of exclusion (strong for cost-effectiveness, high quality; consensus for time-to-therapy), and categorize by IBS subtype (consensus). In patients with IBS and diarrhea symptoms: check celiac serology (strong, moderate) and, in those WITHOUT alarm features, fecal calprotectin (or fecal lactoferrin) plus CRP to rule out IBD (strong; moderate quality for CRP/calprotectin, very low for lactoferrin). Recommend AGAINST routine stool testing for enteric pathogens (conditional, low) and AGAINST routine colonoscopy in patients younger than 45 without warning signs (conditional, low). Anorectal physiology testing only when symptoms suggest a pelvic floor disorder and/or for refractory constipation not responding to standard medical therapy (consensus). Treatment, all subtypes: soluble, not insoluble, fiber (strong, moderate); a LIMITED trial of a low-FODMAP diet (conditional, very low); gut-directed psychotherapies for global symptoms (conditional, very low); TCAs for global symptoms (strong, moderate); peppermint suggested (conditional, low); antispasmodics for abdominal pain (conditional, low); AGAINST probiotics (conditional, very low), AGAINST fecal transplant (strong, very low). IBS-C: chloride channel activators (strong, moderate) and guanylate cyclase activators (strong, high); AGAINST PEG products for global IBS-C symptoms (conditional, low); tegaserod reserved for women younger than 65 with ≤1 cardiovascular risk factor who have not adequately responded to secretagogues (strong/conditional, low). IBS-D: rifaximin (strong, moderate); alosetron only for women with severe IBS-D who have failed conventional therapy (conditional, low); mixed opioid agonists/antagonists, i.e. eluxadoline (conditional, moderate); AGAINST bile acid sequestrants (conditional, very low).
Clinical takeawayIn chronic constipation patients suspected of dyssynergic defecation who cannot or decline HR-ARM, MRD may provide a non-invasive diagnostic alternative with moderate-to-good diagnostic odds ratios (8.25-14.25). Requires prospective external validation and clarification of specific diagnostic thresholds and their directional criteria before adoption as primary diagnostic criteria.
What it foundSpecific quantitative MRD parameters, M-line measurement, anorectal angle (ARA), and anal canal width (ACW), with emphasis on puborectalis muscle prominence or abnormal evacuation assessment, demonstrated discriminatory ability for dyssynergic defecation. Numeric cutoff thresholds (M-line 2.0 cm, ARA 114°, ACW 10 mm) achieved specificities of 82.1-92.3%, positive likelihood ratios of 3.66-7.06, and diagnostic odds ratios of 8.25-14.25; ARA and ACW at defecation were identified as independent predictors. Direction of cutoff relationship to dyssynergic diagnosis specified in source.
ContextDyssynergic defecation is currently diagnosed via high-resolution anorectal manometry combined with functional testing (balloon expulsion). MR defecography is non-invasive dynamic imaging of pelvic floor mechanics during defecation. Prior evidence for MRD diagnostic criteria in dyssynergic defecation is limited. This retrospective study establishes specific MRD measurement thresholds that discriminate dyssynergic defecation from normal, potentially providing an imaging-based diagnostic alternative for patients who cannot or refuse manometry.
Emergingsuggested applicable standard· American Gastroenterological Association & American College of Gastroenterology, "American Gastroenterological Association-American College of Gastroenterology Clinical Practice Guideline: Pharmacological Management of Chronic Idiopathic Constipation" (Chang L, Chey WD, Imdad A, et al.), 2023ShowHide
Decision at stakehow to diagnose dyssynergic defecation in patients presenting with constipation, to determine appropriate management pathway
No single passage of this standard matched the paper closely enough to quote, so none is shown. The standard is cited above.
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In adults with chronic idiopathic constipation, the AGA-ACG panel makes 10 GRADE-based pharmacological recommendations, and the strength tier is part of the recommendation. Unqualified as to prior therapy: STRONG recommendation (moderate certainty) for polyethylene glycol; STRONG recommendation (moderate certainty) for bisacodyl or sodium picosulfate, but explicitly qualified as short-term or rescue therapy; CONDITIONAL suggestion for fiber supplementation (low certainty), magnesium oxide (very low certainty), and senna (low certainty). Reserved for patients who do not respond to, fail, or are intolerant of over-the-counter agents: STRONG recommendation (moderate certainty) for linaclotide, plecanatide, and prucalopride; CONDITIONAL suggestion for lubiprostone (low certainty) and lactulose (very low certainty). The guideline states no specific doses, no mandatory ordering algorithm, and no fixed trial duration; it notes only that nonpharmacological therapies 'often represent the initial steps in management' and directs clinicians to shared decision making incorporating patient preference, cost, and availability. The guideline explicitly does not cover anorectal evacuation disorders, referring those to the ACG 2021 benign anorectal guideline.
Clinical takeawayNo clinical action yet. This observational study describes associations between bile acids, microbiota, and IBS phenotypes but does not establish causality or test therapeutic interventions; whether modifying these factors improves symptoms remains unknown.
What it foundIBS-D is characterized by elevated plasma bile acids (total, primary, secondary, conjugated, and unconjugated) with reduced Ruminococcus and Clostridium, while IBS-C exhibits reduced bile acids with Bacteroides and Clostridium enrichment; specific bacterial taxa correlated differentially with distinct bile acid species.
ContextBuilds on prior evidence linking dysbiosis and bile acids to IBS by characterizing subtype-specific, opposite patterns (IBS-D: elevated bile acids; IBS-C: reduced), suggesting mechanisms for their different clinical manifestations.
Reinforcessuggested applicable standard· American College of Gastroenterology, 'ACG Clinical Guideline: Management of Irritable Bowel Syndrome', 2021ShowHide
Decision at stakecategorize IBS patients by subtype to enable subtype-specific pharmacotherapy
…IBS-D: rifaximin (strong, moderate); alosetron only for women with severe IBS-D who have failed conventional therapy (conditional, low); mixed opioid agonists/antagonists, i.e. eluxadoline (conditional, moderate); AGAINST bile acid sequestrants (conditional, very low).
From our summary of this standard, unedited — the part the paper bears on. … marks omitted text. Our wording, not the guideline's; read the source for its own text. The rest of this standard includes IBS-C.
Our full summary of this standardShowHide
Diagnosis: use a positive diagnostic strategy based on Rome IV criteria rather than a strategy of exclusion (strong for cost-effectiveness, high quality; consensus for time-to-therapy), and categorize by IBS subtype (consensus). In patients with IBS and diarrhea symptoms: check celiac serology (strong, moderate) and, in those WITHOUT alarm features, fecal calprotectin (or fecal lactoferrin) plus CRP to rule out IBD (strong; moderate quality for CRP/calprotectin, very low for lactoferrin). Recommend AGAINST routine stool testing for enteric pathogens (conditional, low) and AGAINST routine colonoscopy in patients younger than 45 without warning signs (conditional, low). Anorectal physiology testing only when symptoms suggest a pelvic floor disorder and/or for refractory constipation not responding to standard medical therapy (consensus). Treatment, all subtypes: soluble, not insoluble, fiber (strong, moderate); a LIMITED trial of a low-FODMAP diet (conditional, very low); gut-directed psychotherapies for global symptoms (conditional, very low); TCAs for global symptoms (strong, moderate); peppermint suggested (conditional, low); antispasmodics for abdominal pain (conditional, low); AGAINST probiotics (conditional, very low), AGAINST fecal transplant (strong, very low). IBS-C: chloride channel activators (strong, moderate) and guanylate cyclase activators (strong, high); AGAINST PEG products for global IBS-C symptoms (conditional, low); tegaserod reserved for women younger than 65 with ≤1 cardiovascular risk factor who have not adequately responded to secretagogues (strong/conditional, low). IBS-D: rifaximin (strong, moderate); alosetron only for women with severe IBS-D who have failed conventional therapy (conditional, low); mixed opioid agonists/antagonists, i.e. eluxadoline (conditional, moderate); AGAINST bile acid sequestrants (conditional, very low).