### 1.1 PURPOSE OF GUIDELINES

These guidelines were compiled by a multidisciplinary group at the request of the chairman of the British Society of Gastroenterology's Clinical Services Committee. The prime targets for these guidelines are consultant gastroenterologists, specialist registrars in training, and general practitioners. The purpose is to identify and inform the key decisions to be made in the management of patients thought to have functional diseases of the gut. As these comprise the commonest conditions seen by gastroenterologists, the working party represented a wide spectrum of practitioners in gastroenterology, including gastroenterologists from both district general hospitals and tertiary referral centres, as well as primary care practitioners, psychiatrists, psychologists, and dietitians.

### 1.2 SPECIFIC DIFFICULTIES

Compared with producing guidelines for the management of well defined diseases such as peptic ulcer where there is a clear disease entity, an obvious end point, and highly effective treatments, drawing up guidelines for functional gastroenterological disorders has had many difficulties. Clinical trials have been difficult to design as the conditions being treated are highly variable with many possible end points, and most therapies only marginally more effective than placebo. Early trials were difficult to evaluate because of inadequate patient definition so that many questions have yet to be addressed with good quality randomised controlled clinical trials. Most of our recommendations are therefore supported by clinical experience rather than randomised controlled clinical trials. Finally, because functional diseases, although potentially debilitating, are non-fatal there are few uniformly available audit measures such as mortality or survival times by which to judge or compare different treatment regimens in different areas of clinical practice.

### 1.3 PROCESS OF GUIDELINE CREATION

The co-chairmen were approached by the chairman of the British Society of Gastroenterology's Clinical Services Committee and invited to form a working party. Members were chosen to be broadly representative of clinicians and academics with a long term interest and publication record in the …

https://gut.bmj.com/content/gutjnl/47/suppl_2/ii1.full.pdf

British Society of Gastroenterology guidelines for the management of the irritable bowel syndrome

Communication between the brain and gut is not one-way, but a bidirectional highway whereby reciprocal signals between the two organ systems are exchanged to coordinate function. The messengers of this complex dialogue include neural, metabolic, endocrine and immune mediators responsive to diverse environmental cues, including nutrients and components of the intestinal microbiota (microbiota-gut-brain axis). We are now starting to understand how perturbation of these systems affects transition between health and disease. The pathological repercussions of disordered gut-brain dialogue are probably especially pertinent in functional gastrointestinal diseases, including IBS and functional dyspepsia. New insights into these pathways might lead to novel treatment strategies in these common gastrointestinal diseases. In this Review, we consider the role of the immune system as the gatekeeper and master regulator of brain-gut and gut-brain communications. Although adaptive immunity (T cells in particular) participates in this process, there is an emerging role for cells of the innate immune compartment (including innate lymphoid cells and cells of the mononuclear phagocyte system). We will also consider how these key immune cells interact with the specific components of the enteric and central nervous systems, and rapidly respond to environmental variables, including the microbiota, to alter gut homeostasis.

The mucosal immune system: master regulator of bidirectional gut-brain communications.

Conceptually, the irritable bowel syndrome (IBS) has been considered a brain‐gut functional disorder, but this paradigm is under serious challenge. There is increasing evidence that organic disease of the gastrointestinal tract can be identified in subsets of patients who fulfil the Rome criteria for IBS. Evidence for subtle inflammatory bowel disease, serotonin dysregulation, bacterial overgrowth and central dysregulation continue to accumulate. The underlying causes of IBS remain to be adequately identified, but postinfectious IBS is a clear‐cut entity. Furthermore, a genetic contribution to IBS also seems likely. Diagnosis continues to be based on the symptom profile and the absence of alarm features. A heightened awareness of coeliac disease masquerading as IBS is becoming accepted. Management remains largely based on symptomatic rather than on disease‐modifying therapy, but this is likely to change in the near future. Here, recent advances in the pathophysiology and management of IBS are considered.

https://www.gastroendonews.com/download/ibsgen0604.pdf

Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) remains one of the most common gastrointestinal disorders seen by clinicians in both primary and secondary care. Since publication of the last British Society of Gastroenterology (BSG) guideline in 2007, substantial advances have been made in understanding its complex pathophysiology, resulting in its re-classification as a disorder of gut-brain interaction, rather than a functional gastrointestinal disorder. Moreover, there has been a considerable amount of new evidence published concerning the diagnosis, investigation and management of IBS. The primary aim of this guideline, commissioned by the BSG, is to review and summarise the current evidence to inform and guide clinical practice, by providing a practical framework for evidence-based management of patients. One of the strengths of this guideline is that the recommendations for treatment are based on evidence derived from a comprehensive search of the medical literature, which was used to inform an update of a series of trial-based and network meta-analyses assessing the efficacy of dietary, pharmacological and psychological therapies in treating IBS. Specific recommendations have been made according to the Grading of Recommendations Assessment, Development and Evaluation system, summarising both the strength of the recommendations and the overall quality of evidence. Finally, this guideline identifies novel treatments that are in development, as well as highlighting areas of unmet need for future research.

https://gut.bmj.com/content/gutjnl/70/7/1214.full.pdf

British Society of Gastroenterology guidelines on the management of irritable bowel syndrome

Objective Our aim was to evaluate the association between visceral hypersensitivity and GI symptom severity in large cohorts of patients with functional GI disorder (FGID) and to adjust for psychological factors and general tendency to report symptoms. Design We included five cohorts of patients with FGIDs (IBS or functional dyspepsia; n=1144), who had undergone visceral sensitivity testing using balloon distensions (gastric fundus, descending colon or rectum) and completed questionnaires to assess GI symptom severity, non-GI somatic symptoms, anxiety and depression. Subjects were divided into sensitivity tertiles based on pain/discomfort thresholds. GI symptom severity was compared between sensitivity tertiles in each cohort and corrected for somatisation, and anxiety and depression. Results In all five cohorts, GI symptom severity increased gradually with increasing visceral sensitivity, with significant differences in GI symptom severity between the sensitivity tertiles (p 2 : 0.047–0.11). The differences between sensitivity tertiles remained significant in all cohorts after correction for anxiety and depression, and also after correction for non-GI somatic symptom reporting in all of the cohorts (p Conclusions A gradual increase in GI symptom severity with increasing GI sensitivity was demonstrated in IBS and functional dyspepsia, which was consistent across several large patient groups from different countries, different methods to assess sensitivity and assessments in different parts of the GI tract. This association was independent of tendency to report symptoms or anxiety/depression comorbidity. These findings confirm that visceral hypersensitivity is a contributor to GI symptom generation in FGIDs.

/pdf/visceral-hypersensitivity-is-associated-with-gi-symptom-1gl7lezk73.pdf

Visceral hypersensitivity is associated with GI symptom severity in functional GI disorders: consistent findings from five different patient cohorts

Histamine Receptor H1-Mediated Sensitization of TRPV1 Mediates Visceral Hypersensitivity and Symptoms in Patients With Irritable Bowel Syndrome

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Histamine Receptor H1-Mediated Sensitization of TRPV1 Mediates Visceral Hypersensitivity and Symptoms in Patients With Irritable Bowel Syndrome