ACG Clinical Guideline: Management of Irritable Bowel Syndrome

Am J Gastroenterol. 2021 Jan 1;116(1):17-44. doi: 10.14309/ajg.0000000000001036.


Irritable bowel syndrome (IBS) is a highly prevalent, chronic disorder that significantly reduces patients' quality of life. Advances in diagnostic testing and in therapeutic options for patients with IBS led to the development of this first-ever American College of Gastroenterology clinical guideline for the management of IBS using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Twenty-five clinically important questions were assessed after a comprehensive literature search; 9 questions focused on diagnostic testing; 16 questions focused on therapeutic options. Consensus was obtained using a modified Delphi approach, and based on GRADE methodology, we endorse the following: We suggest that a positive diagnostic strategy as compared to a diagnostic strategy of exclusion be used to improve time to initiating appropriate therapy. We suggest that serologic testing be performed to rule out celiac disease in patients with IBS and diarrhea symptoms. We suggest that fecal calprotectin be checked in patients with suspected IBS and diarrhea symptoms to rule out inflammatory bowel disease. We recommend a limited trial of a low fermentable oligosaccharides, disacchardies, monosaccharides, polyols (FODMAP) diet in patients with IBS to improve global symptoms. We recommend the use of chloride channel activators and guanylate cyclase activators to treat global IBS with constipation symptoms. We recommend the use of rifaximin to treat global IBS with diarrhea symptoms. We suggest that gut-directed psychotherapy be used to treat global IBS symptoms. Additional statements and information regarding diagnostic strategies, specific drugs, doses, and duration of therapy can be found in the guideline.

Publication types

  • Consensus Development Conference
  • Practice Guideline

MeSH terms

  • Celiac Disease / diagnosis
  • Celiac Disease / immunology
  • Chloride Channel Agonists / therapeutic use*
  • Cognitive Behavioral Therapy*
  • Constipation / physiopathology
  • Constipation / therapy*
  • Delphi Technique
  • Diagnosis, Differential
  • Diarrhea / physiopathology
  • Diarrhea / therapy*
  • Diet Therapy*
  • Disease Management
  • Feces / chemistry
  • Gastroenterology
  • Gastrointestinal Agents / therapeutic use*
  • Guanylyl Cyclase C Agonists / therapeutic use*
  • Humans
  • Hypnosis
  • Inflammatory Bowel Diseases / diagnosis
  • Irritable Bowel Syndrome / diagnosis
  • Irritable Bowel Syndrome / physiopathology
  • Irritable Bowel Syndrome / therapy*
  • Leukocyte L1 Antigen Complex / analysis
  • Rifaximin / therapeutic use
  • Serologic Tests
  • Societies, Medical


  • Chloride Channel Agonists
  • Gastrointestinal Agents
  • Guanylyl Cyclase C Agonists
  • Leukocyte L1 Antigen Complex
  • Rifaximin