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Irritable bowel syndrome with diarrhea: time to change practice?
Cristina Caranfil1,2, Luisa Bertin1,2, Fabiana Zingone1,2
1Department of Surgery, Oncology and Gastroenterology, University of Padua.
Current Opinion in Gastroenterology
|February 9, 2026
Summary
Contemporary evidence supports shifting irritable bowel syndrome with diarrhea (IBS-D) diagnosis and treatment. Focus is now on targeted investigations and mechanism-based therapies, including neuromodulators and dietary changes, for better patient outcomes.
Area of Science:
- Gastroenterology
- Neuroimmunology
- Clinical Practice Guidelines
Background:
- Traditional irritable bowel syndrome with diarrhea (IBS-D) management involved extensive exclusionary testing and empirical symptom control.
- Recent advancements in neuroimmune pathophysiology, diagnostics, biomarkers, and treatment efficacy necessitate a re-evaluation of current IBS-D practices.
Purpose of the Study:
- To evaluate if accumulated evidence warrants significant changes in contemporary diagnostic and therapeutic practices for IBS-D.
- To assess the impact of new understanding in neuroimmune pathways and novel biomarkers on IBS-D management.
Main Methods:
- Review of recent systematic reviews and emerging evidence on diagnostic algorithms and treatment efficacy.
- Analysis of novel biomarkers and their potential role in IBS-D diagnosis.
- Evaluation of therapeutic strategies including neuromodulators, dietary interventions, and behavioral therapies.
Main Results:
- Diagnostic approaches are shifting towards symptom-based strategies with targeted testing for specific conditions.
- Emerging biomarkers like neutrophil-to-albumin ratio and microRNA-148 show diagnostic potential.
- Effective treatments include tricyclic antidepressants, low FODMAP and Mediterranean diets, and brain-gut behavioral therapies.
Conclusions:
- Evidence supports a shift from exclusionary testing to targeted investigations of treatable conditions.
- Mechanism-based multimodal interventions integrating neuromodulators, diet, and behavioral therapies are recommended.
- Individualized treatment selection based on phenotype and comorbidities, delivered via integrated care models, is crucial for optimal IBS-D management.
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