United European Gastroenterol J. 2022 Jul;10(6):556-584. doi: 10.1002/ueg2.12259.Epub 2022 Jun 13.

Edoardo Savarino ¹, Fabiana Zingone ¹, Brigida Barberio ¹, Giovanni Marasco ^2 3, Filiz Akyuz ⁴, Hale Akpinar ⁵, Oana Barboi ^6 7, Giorgia Bodini ⁸, Serhat Bor ⁹, Giuseppe Chiarioni ¹⁰, Gheorghe Cristian ¹¹, Maura Corsetti ^12 13, Antonio Di Sabatino ¹⁴, Anca Mirela Dimitriu ¹⁵, Vasile Drug ^6 7, Dan L Dumitrascu ¹⁶, Alexander C Ford ^17 18, Goran Hauser ¹⁹, Radislav Nakov ²⁰, Nisha Patel ²¹, Daniel Pohl ²², Catalin Sfarti ^6 7, Jordi Serra ^23 24 25, Magnus Simrén ²⁶, Alina Suciu ¹⁵, Jan Tack ²⁷, Murat Toruner ²⁸, Julian Walters ^29 30, Cesare Cremon ^2 3, Giovanni Barbara ^2 3

Author information

¹Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy.

²Division of Internal Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.

³Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.

⁴Department of Gastroenterology, Istanbul University Istanbul School of Medicine, Istanbul, Turkey.

⁵Department of Internal Medicine, Dokuz Eylül University School of Medicine, Izmir, Turkey.

⁶Department of Gastroenterology, 'Grigore T. Popa' University of Medicine and Pharmacy, Iasi, Romania.

⁷Institute of Gastroenterology and Hepatology, 'Saint Spiridon' Hospital, Iasi, Romania.

⁸Gastrointestinal Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy.

⁹Division of Gastroenterology, Ege University School of Medicine, Izmir, Turkey.

¹⁰Division of Gastroenterology, University of Verona, Verona, Italy.

¹¹Fundeni Clinical Institute Center of Gastroenterology and Hepatology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.

¹²National Institute for Health Research, Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK.

¹³Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK.

¹⁴First Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, University of Pavia, Pavia, Italy.

¹⁵Center of Gastroenterology and Hepatology, Fundeni Clinical Institute, University of Medicine and Pharmacy, Bucharest, Romania.

¹⁶2nd Department of Internal Medicine, 'Iuliu Hatieganu' University of Medicine and Farmacy, Cluj-Napoca, Romania.

¹⁷Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK.

¹⁸Leeds Institute of Medical Research at St. James's Sciences, University of Leeds, Leeds, UK.

¹⁹Department of Gastroenterology, Clinical Hospital Center Rijeka, Faculty of Medicine, University of Rijeka, Rijeka, Croatia.

²⁰Department of Gastroenterology, Tsaritsa Yoanna University Hospital, Medical University of Sofia, Sofia, Bulgaria.

²¹Imperial College Healthcare NHS Trust, Institute of Global Health Innovation, St Mary's Hospital Campus, London, UK.

²²Department of Gastroenterology, University Hospital Zurich, Zurich, Switzerland.

²³Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Badalona, Spain.

²⁴Digestive System Research Unit, University Hospital Vall d'Hebron, Barcelona, Spain.

²⁵Department of Medicine, Autonomous University of Barcelona, Badalona, Spain.

²⁶Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.

²⁷Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium.

²⁸Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey.

²⁹Division of Digestive Diseases, Department of Metabolism, Digestion, and Reproduction, Faculty of Medicine, Imperial College London, London, UK.

³⁰Department of Gastroenterology, Division of Medicine and Integrated Care, Imperial College Healthcare NHS Trust, London, UK.

Abstract

Irritable bowel syndrome with diarrhoea (IBS-D) and functional diarrhoea (FDr) are the two major functional bowel disorders characterized by diarrhoea. In spite of their high prevalence, IBS-D and FDr are associated with major uncertainties, especially regarding their optimal diagnostic work-up and management. A Delphi consensus was performed with experts from 10 European countries who conducted a literature summary and voting process on 31 statements. Quality of evidence was evaluated using the grading of recommendations, assessment, development, and evaluation criteria. Consensus (defined as >80% agreement) was reached for all the statements. The panel agreed with the potential overlapping of IBS-D and FDr. In terms of diagnosis, the consensus supports a symptom-based approach also with the exclusion of alarm symptoms, recommending the evaluation of full blood count, C-reactive protein, serology for coeliac disease, and faecal calprotectin, and consideration of diagnosing bile acid diarrhoea. Colonoscopy with random biopsies in both the right and left colon is recommended in patients older than 50 years and in presence of alarm features. Regarding treatment, a strong consensus was achieved for the use of a diet low fermentable oligo-, di-, monosaccharides and polyols, gut-directed psychological therapies, rifaximin, loperamide, and eluxadoline. A weak or conditional recommendation was achieved for antispasmodics, probiotics, tryciclic antidepressants, bile acid sequestrants, 5-hydroxytryptamine-3 antagonists (i.e. alosetron, ondansetron, or ramosetron). A multinational group of European experts summarized the current state of consensus on the definition, diagnosis, and management of IBS-D and FDr.