The management of patients with
irritable bowel syndrome (IBS) is a frequent, yet challenging task in both primary care and gastroenterology practice. A diagnostic strategy guided by keen clinical judgment should focus on positive symptom criteria and on the absence of alarm symptoms. In younger patients lacking alarm features, invasive testing has a low-yield. The presence of
food intolerance and underlying
celiac disease should be excluded. The usefulness of fecal tests such as
calprotectin and
lactoferrin to exclude organic bowel disease is not adequately established. In patients with moderate to severe symptoms who fail initial therapeutic trials, further tests can be performed in tertiary care settings, such as transit measurement and tests for diagnosing pelvic floor dysfunction. Treatment strategies for IBS are currently directed at the predominant symptoms. In
diarrhea-predominant IBS,
opioids (e.g.
loperamide) and the 5-HT(3) receptor antagonist
alosetron are efficacious. In
constipation-predominant IBS, fiber and
bulk laxatives are traditionally used, but their efficacy is variable and may worsen symptoms. The 5-HT(4) receptor agonist
tegaserod is efficacious in female patients with IBS and
constipation. In patients with IBS and
abdominal pain,
antispasmodics and
antidepressants can be used, with the best evidence supporting the prescription of
tricyclic antidepressants. The efficacy of psychological treatments in terms of relieving the symptoms of IBS is still uncertain. Limited evidence suggests that anti-
enkephalinase agents,
somatostatin analogues, alpha(2)-receptor agonists,
opioid antagonists,
selective serotonin reuptake inhibitors, probiotics and herbal treatments may be useful in IBS patients.