Authors: Wellens J, Sabino J, Vanuytsel T, Tack J, Vermeire S
Journal: Gut
Year: 2025
Volume: 74
Pages: 312–321
DOI: 10.1136/gutjnl-2024-333565
Study at a glance
- Study type: Narrative review
- Population studied: Patients with inflammatory bowel disease (IBD) experiencing irritable bowel syndrome (IBS) type symptoms in remission
- Key focus: Prevalence, pathophysiology, diagnosis and treatment of IBS-like symptoms in patients with IBD
Why was this study done?
Many patients with IBD continue to report abdominal pain, bloating and altered bowel habits despite successful treatment of gut inflammation. Although IBS cannot by definition be diagnosed in someone with IBD, IBS-type symptoms in patients with IBD in remission occur five times more frequently than in the general population.
These persisting symptoms reduce quality of life and increase healthcare use including additional clinic visits and invasive procedures. The authors reviewed current knowledge to help clinicians better understand and manage this common clinical challenge.
How was the study performed?
Wellens and colleagues reviewed published research examining IBS-like symptoms in patients with IBD. They examined studies on prevalence, underlying mechanisms and treatment approaches, synthesising evidence from systematic reviews, meta-analyses (studies combining results from multiple previous studies), observational studies and trials.
What did the researchers find?
Approximately one quarter of patients with IBD in histological remission (confirmed by microscopic examination showing no active inflammation in bowel tissue samples) report IBS-like symptoms. In patients with IBD in remission, prevalence was higher in Crohn’s disease at 36.6% compared with ulcerative colitis at 28.7%. Importantly, symptoms occur even when deep remission is achieved with no visible inflammation on endoscopy or microscopy.
Several shared mechanisms between IBS and IBD may explain these symptoms: genetic susceptibility, environmental triggers, gut bacteria changes (dysbiosis), increased intestinal permeability (when the gut lining becomes more porous) and visceral hypersensitivity (heightened pain perception in the digestive tract). The interaction between gut and brain, including psychological factors such as anxiety and depression, plays an important role in both conditions.
Whilst low-grade inflammation may contribute in some patients, many with well-controlled IBD and no detectable inflammation still experience troublesome symptoms. Studies showed that IBS-like symptoms were not associated with increased need for corticosteroids, disease flare, treatment escalation or hospitalisation, suggesting symptoms may not reflect harmful ongoing inflammation.
Several factors may trigger or worsen symptoms. After inflammatory episodes, patients may develop sensitisation to food components, leading to mast cell activation (immune cells releasing substances causing pain and inflammation when activated). Changes in gut microbiota and increased proteolytic enzyme activity (proteins breaking down other proteins in the gut) have also been linked to abdominal pain and visceral hypersensitivity.
Psychological factors are prominent. Patients with IBS-like symptoms showed higher rates of anxiety and depression. Stress can trigger inflammatory responses and affect gut motility (food movement through the digestive tract) through the autonomic nervous system (controlling automatic body functions).
What did the authors conclude?
IBS-like symptoms affect a substantial proportion of patients with IBD in remission and significantly impact quality of life and healthcare use. Whilst controlling inflammation remains essential, treatment goals should be broadened to include symptom relief and improved quality of life, not solely endoscopic healing.
After confirming remission and excluding other conditions such as coeliac disease, bile acid diarrhoea, small intestinal bacterial overgrowth or food intolerances, clinicians should adopt a symptom-based diagnostic approach, considering psychological factors early.
Treatment should be multimodal, potentially combining dietary approaches, lifestyle modifications, medications acting on gut motility or pain perception, and psychological therapies. Evidence specifically for treating IBS-like symptoms in IBD is limited, but therapies used successfully in classical IBS may be beneficial.
The authors emphasised the need for clinical trials specifically examining treatments for IBS-like symptoms in patients with IBD in remission, calling for increased awareness among IBD specialists regarding functional symptom management and timely referral to specialists in disorders of gut and brain interaction when appropriate.
Key takeaways
- Approximately 25% of patients with IBD in histological remission experience IBS-like symptoms, with higher rates in Crohn’s disease than ulcerative colitis.
- Shared mechanisms between IBD and IBS include genetic factors, gut microbiota changes, increased intestinal permeability, visceral hypersensitivity and gut and brain interactions.
- IBS-like symptoms in IBD are associated with reduced quality of life and increased healthcare utilisation, but not with increased risk of disease flare or need for treatment escalation.
- After excluding ongoing inflammation and other gastrointestinal conditions, a symptom-based approach focusing on the main complaint (pain, bloating, diarrhoea or constipation) should guide diagnosis and treatment.
- Treatment should be multimodal and may include dietary modification, lifestyle changes, medications and psychological therapies, with management goals extending beyond inflammatory control to include symptom relief and quality of life.
This Scientific Publication Summary is an objective summary of the published study for personal and educational use. It does not constitute medical advice, endorsement of the intervention, or a recommendation to alter clinical practice.