Dilemma in post-IBD patients with IBS-D symptoms: A 2020 overview

ABSTRACT

Introduction

Inflammatory bowel disease (IBD) patients in apparent clinical remission who present with irritable bowel syndrome (IBS)-like symptoms pose a diagnostic and therapeutic dilemma that is called post-IBD IBS. When associated with a diarrheal IBS presentation, this clinical syndrome is known as post-IBD IBS-D.

Areas covered

We review and describe the literature regarding the clinical overlap of IBD and IBS. We discuss prevalent theories regarding the pathophysiology of post-IBD IBS-D and whether this presentation represents coincident inherent IBS-D, IBS-D triggered by IBD, or an even more subtle level of IBD activity that is unrecognized by available laboratory modalities. We also discuss observations that post-IBD IBS-D patients harbor significantly increased colon mucosal eosinophils and appear to respond to a GI-hypoallergenic diet and budesonide therapy.

Expert opinion

The symptoms overlap between IBD and IBS complicates diagnosis and subsequent management of patients with post-IBD IBS-D. In addition to current theories regarding the pathophysiology of this condition such as alterations in mucosal inflammation, the microbiota, mucosal permeability, and gut–brain interactions. This new avenue of eosinophilic colopathy and therapy directed toward food-derived immune response in patients with post-IBD IBS-D deserves additional investigation.

KEYWORDS:

• Inflammatory bowel disease
• irritable bowel syndrome
• food allergy
• colon mucosal eosinophils
• eosinophilic colopathy

Article highlights

• Inflammatory bowel disease patients in clinical remission who present with IBS-like symptoms pose a diagnostic and therapeutic dilemma that is called post-IBD IBS.

• This common syndrome with unknown etiology was first reported in 1983 and may have a multifactorial pathophysiology, including environmental and psychological alterations, GI motility disarray, increased intestinal permeability, genetic variability, and possibly gut microbiome derangements.

• Our retrospective, single-center randomized study in 20 Crohn’s disease and 15 CUC patients with post-IBD IBS-D symptoms showed significantly increased mucosal eosinophils in their colon biopsies (eosinophilic colopathy) compared to 15 inactive IBD patients without post-IBD IBS-D.

• Sixty-seven percent of these 35 patients with post-IBD IBS-D and eosinophilic colopathy responded well clinically to the GI-hypoallergenic (five food elimination) diet and budesonide therapy within 7–10 days.

• Large randomized studies are needed in this common clinical dilemma in patients with post-IBD IBS the role of food allergens should be investigated.

Declaration of interest

The authors have no relevant affiliation or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper is funded by the Ertan Education and Research Foundation, University Texas Health Science Center at Houston, McGovern Medical School.