Opinion Review
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jul 14, 2020; 26(26): 3712-3719
Published online Jul 14, 2020. doi: 10.3748/wjg.v26.i26.3712
Functional gastrointestinal disorders in inflammatory bowel disease: Time for a paradigm shift?
Dipesh H Vasant, Alexander C Ford
Dipesh H Vasant, Gastroenterology, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester M23 9LT, United Kingdom
Dipesh H Vasant, Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester M23 9LT, United Kingdom
Alexander C Ford, Leeds Institute of Medical Research at St. James’s, University of Leeds, Leeds LS9 7TF, United Kingdom
Alexander C Ford, Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF, United Kingdom
Author contributions: Vasant DH and Ford AC both reviewed the literature; Vasant DH wrote the paper; Ford AC reviewed and helped write the paper, and provided important intellectual input.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Dipesh H Vasant, MBChB, MRCP, PhD, Senior Lecturer, Gastroenterology, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Southmoor Road, Manchester M23 9LT, United Kingdom. dipesh.vasant@mft.nhs.uk
Received: March 28, 2020
Peer-review started: March 28, 2020
First decision: April 18, 2020
Revised: April 23, 2020
Accepted: July 1, 2020
Article in press: July 1, 2020
Published online: July 14, 2020

Recent advances in biological therapies have revolutionalised and redefined treatment targets in inflammatory bowel disease (IBD). There is now a stronger emphasis on achieving the more stringent therapeutic goals of mucosal and histological healing, rather than clinical remission alone. Consequently, the treatment of refractory “functional” gastrointestinal symptoms, often attributed as the aftermath of previous inflammation, has recently become more prominent in quiescent disease. With further expected advances in anti-inflammatory treatments on the horizon, the burden of such symptoms in quiescent disease, which have been relatively neglected, is set to become an even bigger problem. In this article, we highlight the current state of research and understanding in this field, including recent developments and clinical practice guidelines on the diagnosis and management of functional gastrointestinal symptoms, such as irritable bowel syndrome and functional anorectal and pelvic floor disorders, in patients with quiescent IBD. These disorders are not only highly prevalent in these patients, they are often misdiagnosed, and are difficult to treat, with very few evidence-based therapies. Moreover, they are associated with substantial impairment in quality-of-life, considerable morbidity, and psychological distress. There is therefore an urgent need for a change in emphasis towards earlier recognition, positive diagnosis, and targeted treatment for patients with ongoing functional gastrointestinal symptoms in the absence of active IBD. This article also highlights the need for further research to develop much needed evidence-based therapies.

Keywords: Irritable bowel syndrome, Inflammatory bowel disease, Functional gastrointestinal disorders, Faecal incontinence, Pelvic floor dyssynergia

Core tip: Functional gastrointestinal symptoms, in the absence of inflammation, affect around one-third of inflammatory bowel disease (IBD) patients in remission, causing significant psychological distress and impairment of quality of life. As IBD therapies continue to advance, functional gastrointestinal symptoms, as a consequence of previous inflammation, are set to become a bigger problem. Here, we review the current evidence base, highlight a recently proposed diagnostic algorithm, and discuss empirical treatment guidance for functional gastrointestinal symptoms in quiescent IBD. We also discuss future considerations and areas of unmet need to stimulate further research.