Controlling intestinal inflammation does not necessarily mean controlling symptoms. Abdominal pain, bloating and altered bowel habits can persist in patients with inflammatory bowel disease (IBD) even when objective assessments suggest that the disease is in remission. To address this clinical challenge, an international multidisciplinary panel of experts has published a consensus in Gastroenterology in 2026. This is the first joint Rome Foundation/International Organization for the Study of Inflammatory Bowel Disease (IOIBD) consensus specifically addressing the nomenclature, evaluation and management of irritable bowel syndrome (IBS)-like symptoms in patients with IBD. We spoke with Professor Giovanni Barbara of the University of Bologna, an expert in disorders of gut–brain interaction, the gut microbiota, and one of the authors of the consensus, about what these recommendations mean in clinical practice.

 

Why was this consensus needed?

The problem is common: an evidence synthesis of 33 studies involving 4,357 participants found a pooled prevalence of IBS-like symptoms of approximately 30%. For Barbara, this highlights an essential distinction: inflammatory remission and symptom resolution are not the same outcome. “Controlling intestinal inflammation does not always resolve the symptoms that matter most to patients,” Barbara explains. Until now, variation in how these symptoms are described, investigated and managed has created two opposing risks: escalating IBD treatment when inflammation is not driving the symptoms, or leaving patients without an adequate explanation or treatment plan.

 

What is new in the consensus:

  • Terminology matters

The consensus recommends the term “IBD with IBS-like symptoms”. The authors describe these symptoms as abdominal pain, altered bowel habits and/or bloating that are not explained by active inflammation or structural disease. Barbara explains that in a patient with established IBD, the same symptoms can have very different origins: “In someone with established IBD, similar symptoms require additional interpretation because inflammation, strictures, previous surgery or other complications may produce the same complaints”. The terminology therefore preserves the patient’s IBD diagnosis while recognizing that symptoms can arise through mechanisms beyond active inflammation, including altered motility, visceral hypersensitivity, impaired barrier function and changes in gut–brain communication.

  • A more structured diagnosis

The consensus supports combining Rome clinical criteria with objective assessment of inflammatory activity. In practice, Barbara emphasizes looking beyond a single biomarker. Assessment should start with the symptoms and their impact, alongside the patient’s medical and surgical history, medications, diet and psychosocial context. Fecal calprotectin and C-reactive protein (CRP) are useful, but should be interpreted alongside endoscopic findings and, when indicated, histology or imaging. “Normal biomarkers do not exclude every form of active disease, particularly small-bowel Crohn’s disease. Persistent diarrhea may also warrant investigation for other causes, including infection and bile acid malabsorption,” Barbara explains. The clinical principle is clear: if inflammation is active, optimize IBD treatment; if inflammation is absent or insufficient to explain the symptoms, address the predominant IBS-like symptoms. Sometimes both approaches are needed.

  • A broader treatment approach

The consensus considers several approaches appropriate, including psyllium in the absence of a clinically relevant stricture, a short-term low-FODMAP diet, symptom-targeted pharmacological treatments and brain–gut behavioral therapies. Barbara emphasizes that this range of options reflects the multiple mechanisms potentially underlying symptoms: “A single treatment is unlikely to address every patient’s needs.” Treatment should therefore be individualized according to predominant symptoms, bowel pattern, nutritional status, psychological burden and patient preferences.

Psyllium, a soluble, gel-forming fiber, may help regulate stool consistency and improve bowel symptoms. However, the consensus recommends considering disease anatomy first: increasing intestinal bulk in a narrowed bowel segment could aggravate obstructive symptoms.

The evidence supports a short-term low-FODMAP diet (4 to 8 weeks) rather than indefinite restriction. The approach should involve reintroduction and personalization, ideally with dietetic support. It is particularly important in patients with IBD who may already be nutritionally vulnerable or avoiding multiple foods. As Barbara stresses: “The low-FODMAP approach treats IBS-like symptoms; it should not be presented as a replacement for treatment directed at intestinal inflammation.”

The consensus also supports brain–gut behavioral therapies, including gastrointestinal-focused cognitive behavioral therapy, gut-directed hypnotherapy and relevant mindfulness-based interventions. Their inclusion does not imply that symptoms are simply psychological. As Barbara explains, these interventions can address heightened attention to gastrointestinal sensations, fear of symptoms and avoidance behaviors that can amplify pain and interfere with daily life.

 

What should clinicians take away for clinic practice?

The immediate message is that persistent symptoms alone should not automatically trigger escalation of anti-inflammatory or immunosuppressive therapy. Clinicians first need to establish whether inflammation or structural disease adequately explains the symptoms. When it does not, the remaining symptom burden deserves its own evaluation and treatment. Important challenges remain, including the need for better disease-specific measures, larger controlled trials and clearer definitions of inflammatory remission. Access to dietitians and clinicians trained in brain–gut behavioral therapies is also uneven. Could the gut microbiome eventually help clinicians distinguish active IBD from IBS-like symptoms? Barbara sees important research opportunities but draws a clear line between future potential and current clinical practice: “The consensus does not establish microbiota profiling as a validated diagnostic tool for this purpose.” Future approaches could potentially combine microbial function and metabolites with inflammatory markers, measures of barrier function and clinical characteristics.

 

 

Reference:

Ma C, Ford AC, Hashash JG, et al. Recommendations for the Evaluation and Management of Inflammatory Bowel Disease With Irritable Bowel Syndrome–Like Symptoms: A Joint Rome Foundation and International Organization for the Study of IBD (IOIBD) Consensus. Gastroenterology. 2026. https://www.gastrojournal.org/article/S0016-5085(26)06758-2/fulltext