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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.

Functional dyspepsia (FD) is a common disorder of gut–brain interaction, affecting approximately 7% of individuals in the community, with most patients managed in primary care. The last British Society of Gastroenterology (BSG) guideline for the management of dyspepsia was published in 1996. In the interim, substantial advances have been made in understanding the complex pathophysiology of FD, and there has been a considerable amount of new evidence published concerning its diagnosis and classification, with the advent of the Rome IV criteria, and management. 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 diagnosis and treatment of patients. The approach to investigating the patient presenting with dyspepsia is discussed, and efficacy of drugs in FD summarised based on evidence derived from a comprehensive search of the medical literature, which was used to inform an update of a series of pairwise and network meta-analyses. Specific recommendations have been made according to the Grading of Recommendations Assessment, Development and Evaluation system. These provide both the strength of the recommendations and the overall quality of evidence. Finally, in this guideline, we consider novel treatments that are in development, as well as highlighting areas of unmet need and priorities for future research.

Purpose It has been well established that how irritable bowel syndrome (IBS) patients respond to their illness experiences (physical, psychological) has a great impact on their symptoms, psychosocial functioning and quality of life. Recently it has been shown that using acceptance coping strategies (rather than control coping strategies) is linked to positive outcomes in several chronic illness contexts (e.g. chronic pain, diabetes, epilepsy). This study is intended to evaluate the factor structure and other psychometric properties of an acceptance measure adapted for the IBS population (IBSAAQ) and to investigate its possible utility in the prediction of key IBS outcomes. Methods A sample of 121 IBS patients attending a specialized gastroenterology clinic completed a series of self-report measures assessing acceptance of IBS, general acceptance, symptom severity, IBS impact on quality of life, general quality of life, gastrointestinal-specific anxiety, avoidant coping behaviours, depression, anxiety and stress. Results Factor analysis supported a 2-factor structure explaining 48.5 % of variance. The total scale and its subscales (activity engagement/IBS willingness) were found to have adequate internal consistency (all α's > 0.80) and test—retest stability. Correlation analyses showed good convergent and concurrent validity. Regression analyses showed that the IBSAAQ and its subscales significantly contributed to the prediction of IBS outcomes. Conclusion The IBSAAQ is a valid and reliable measure of acceptance in IBS. This measure might be of use for the study of the impact of coping strategies on outcomes in IBS and of the effectiveness of acceptance-based approaches (e.g. acceptance and commitment theraphy).

Background: Linaclotide, a guanylate cyclase C agonist, has been shown in clinical trials to improve symptoms of irritable bowel syndrome with constipation (IBS-C). Here we report data from a real-world study of linaclotide in the UK. Methods: This 1-year, multicentre, prospective, observational study in the UK enrolled patients aged 18 years and over initiating linaclotide for IBS-C. The primary assessment was change from baseline in IBS Symptom Severity Scale (IBS-SSS) score at 12 weeks, assessed in patients with paired baseline and 12-week data. Change from baseline in IBS-SSS score at 52 weeks was a secondary assessment. Adverse events were recorded. Results: In total, 202 patients were enrolled: 185 (91.6%) were female, median age was 44.9 years (range 18.1–77.2) and 84 (41.6%) reported baseline laxative use. Mean (standard deviation) baseline IBS-SSS score was 339 (92), with most patients (n = 129; 66.8%) classified as having severe disease (score ⩾300). In patients with paired data, there was a significant mean (95% confidence interval) decrease in IBS-SSS score from baseline to 12 weeks [−77.0 (−96.3, −57.7); p < 0.001; n = 124] and baseline to 52 weeks [−70.7 (−95.0, −46.5); p < 0.001; n = 76]. Overall, 174 adverse events were reported in 77 (38.1%) patients, most commonly diarrhoea (n = 54; 26.7%), abdominal pain (n = 21; 10.4%) and abdominal distension (n = 13; 6.4%). Conclusion: Linaclotide significantly improved IBS-SSS score at 12 and 52 weeks. These results provide insights into outcomes with linaclotide treatment over 1 year in patients with IBS-C in real-world clinical practice.

IntroductionThe Rome Foundation stated recommendations in 2016 to report confounding factors in clinical trials concerning functional gastrointestinal disorders (FGIDs) [1]. The aim of our study was to assess the reporting of different comorbidities and overlap syndromes in patients with functional dyspepsia (FD).MethodsRandomised controlled trials (RCTs) that included adult patients with FD according to Rome criteria were selected via MEDLINE (PubMed®) and Scopus between 2006 and 2021. Characteristics of the trials and the patients, exclusion criteria, psychological factors, other FGIDs, somatic disorders, and non-gastrointestinal (GI) diseases were all recorded. We analysed the level of reporting of these comorbidities, focussing on the most frequent (gastro-oesophageal reflux disease (GORD), irritable bowel syndrome (IBS), anxiety, depression, Helicobacter pylori infection, diabetes mellitus). The study selection and data extraction were performed by FW; the systematic review was registered in PROSPERO (CRD42021235219).Results108 articles were included in the final analysis. Clinical trials were mainly conducted in Asia (76.9%) and involved a complementary and alternative medicine treatment in 45.4% of the cases. The mean number of reported comorbidities was 2.44 (± 1.23 SD). Only one paper reported all six comorbidities. 96.3% of the papers reported at least one comorbidity. 22.2% of papers reported anxiety, and 24.1% reported depression. 63.0% of the papers reported an overlap with GORD and 43.5% with IBS. H. pylori gastritis and diabetes mellitus were reported in 54.6% and 37.0% of the papers respectively. There was no reported overlap with non-GI comorbidities, but for headaches that were reported in 2.8% of the papers. Representation of the reporting of different comorbidities is shown in Figure 1. The reporting of overlaps and comorbidities during the study period remained unchanged.ConclusionsThe most reported comorbidities in FD trials are depression and anxiety levels, overlaps with gastro-oesophageal reflux and IBS, H. pylori gastritis and diabetes mellitus. Overall, at least one of these co-morbidities was reported in almost all articles, with a mean of about 2.5 comorbidities reported in each one.Abstract PWE-62 Figure 1Representation of the proportion of the articles reporting each comorbidityReferenceIrvine EJ, Tack J, Crowell MD, Gwee KA, Ke M, Schmulson MJ, et al. Design of Treatment Trials for Functional Gastrointestinal Disorders. Gastroenterology 2016;150:1469-80 e1.

IntroductionIrritable bowel syndrome (IBS) is a prevalent functional gastrointestinal disorder. Previous studies showed that ‘Acceptance’ can predict quality of life and illness behaviour [1]. A patient education leaflet (EL) was developed to promote patient education and thus patient acceptance and empowerment.Methods30 consecutive patients attending a Specialist Motility clinic at a Tertiary referral centre completed a questionnaire to identify current patients’ knowledge on IBS. Patients were asked to suggest what type of information and in what format, they felt was needed. The data was collected and analysed. Based on patients’ preferences an EL was developed. EL included definition, symptoms, causes, and management of IBS. EL was then distributed to patients attending clinics and their views on this leaflet were recorded.ResultsOnly 30% of patients received information regarding their condition prior to attending the Specialist clinic. 60% of patients expressed the need for further education regarding their symptoms and management. 57% of patients preferred information in the form of a leaflet and only 30% requested workshops on IBS or an app in addition to EL. Workshops were suggested as an additional more interactive approach. Patients’ preference for EL was to include an extra session on pathophysiology of symptoms. No correlation was noted between the duration of symptoms and patients’ knowledge. One patient (4%) did not find that the education provided via EL helped them understand their condition or symptoms (see Figure 1).Abstract PWE-078 Figure 1Has the education leaflet helped you understand your condition or symptoms?ConclusionsThis study demonstrates the need for patient education and empowerment in IBS. The EL was well received. Patients were keen on gastrointestinal pathophysiology and lifestyle changes as addressed in the leaflet. Patients’ educational needs may be enriched with additional workshops and future App-development. It would be of interest to perform a second questionnaire to assess patients’ quality of life and management of IBS symptoms before and after utilization of EL. The patients’ educational level should be accounted for in future studies to ensure appropriate deliverance of EL in IBS patients with learning difficulties.ReferenceFerreira, et al., 2011. Using Acceptance and Commitment Therapy to understand and improve outcomes in Irritable Bowel Syndrome. Gastrointestinal Nursing; vol. 9 (9): 2–5.

Background Irritable bowel syndrome with diarrhoea (IBS-D) affects up to 4% of the general population. Symptoms include frequent, loose, or watery stools with associated urgency, resulting in marked reduction of quality of life and loss of work productivity. Ondansetron, a 5HT 3 receptor antagonist, has had an excellent safety record for over 20 years as an antiemetic, yet is not widely used in the treatment of IBS-D. It has, however, been shown to slow colonic transit and in a small randomised, placebo-controlled, cross-over pilot study, benefited patients with IBS-D. Methods This trial is a phase III, parallel group, randomised, double-blind, multi-centre, placebo-controlled trial, with embedded mechanistic studies. Participants ( n = 400) meeting Rome IV criteria for IBS-D will be recruited from outpatient and primary care clinics and by social media to receive either ondansetron (dose titrated up to 24 mg daily) or placebo for 12 weeks. Throughout the trial, participants will record their worst abdominal pain, worst urgency, stool frequency, and stool consistency on a daily basis. The primary endpoint is the proportion of “responders” in each group, using Food and Drug Administration (FDA) recommendations. Secondary endpoints include pain intensity, stool consistency, frequency, and urgency. Mood and quality of life will also be assessed. Mechanistic assessments will include whole gut transit, faecal tryptase and faecal bile acid concentrations at baseline and between weeks 8 and 11. A subgroup of participants will also undergo assessment of sensitivity ( n  = 80) using the barostat, and/or high-resolution colonic manometry ( n  = 40) to assess motor patterns in the left colon and the impact of ondansetron. Discussion The TRITON trial aims to assess the effect of ondansetron across multiple centres. By defining ondansetron’s mechanisms of action we hope to better identify patients with IBS-D who are likely to respond. Trial registration ISRCTN, ISRCTN17508514 , Registered on 2 October 2017.

BackgroundMore than 50% of patients presenting with cauda equina syndrome (CES) have normal imaging. These patients require phenotyping to ascertain symptom aetiology and mechanism.Prospective Study Results198 patients presented with suspected CES over 28 months. 47 were diagnosed with ‘scan-positive’ CES (mean age 48yrs, 43% female). 76 patients had evidence of nerve root compres- sion or displacement and were placed into a ‘mixed’ category (mean age 46yrs, 71% female) and 61 patients had normal scans ‘scan-negative’ CES (mean age 40yrs, 77% female). Fourteen patients had a neurological diagnosis explaining their clinical CES symptoms during admission.Patients with ‘scan-positive’ CES were more likely to have reduced or lost bilateral ankle jerks (78% vs. 30% and 12%, p≤0.0001). Patients with ‘scan-negative’ CES were found to have positive signs of a functional neurological disorder on examination (11% v. 34% and 68%, p≤0.0001) as well as high rates of panic, medication usage and psychopathology. Four patients out of 151 (4%, mixed group n=3, ‘scan-negative’ group n=1) had a neurological diagnosis after discharged which potentially explained their clinical CES presentation.ConclusionsThis is the first well phenotyped, prospective study of patients with ‘scan-negative’ CES dem- onstrating a pain, medication and functional mechanism of symptom production.ingrid.hoeritzauer@ed.ac.uk

IntroductionDisorders of gut-brain interaction (DGBI) account for a significant proportion of the budget for healthcare in the UK and the workload of gastroenterologists. However, there is minimal epidemiological data comparing the prevalence and impact of DGBI in the UK to other countries. We therefore compared the national prevalence of each of the 22 DGBI in the UK, to data from 25 other countries that participated in the Rome Foundation Global Epidemiology study (RFGES).MethodsThe RFGES study was conducted in 26 countries via the internet under the auspices of the Rome Foundation Research Institute. The online survey had multiple built-in quality-assurance techniques and included the Rome IV diagnostic questionnaire for DGBI and an in-depth supplemental questionnaire. Data were analysed to compare sociodemographic data and UK national prevalence data with pooled prevalence rates across the other 25 countries.ResultsOverall, 2,027 participants from the UK, and 52,100 from the other 25 countries participated. 37.6% of the UK participants (95% CI 36.0–40.0) had at least one DGBI, compared with 41.2% (95% CI 39.0–43.0) for the other 25 countries (p<0.001). The prevalence of DGBI were uniform across all regions within the UK. The UK prevalence of 14 of 22 Rome IV DGBI, including irritable bowel syndrome (4.3%) and functional dyspepsia (6.8%), were similar to the other countries. Faecal incontinence, opioid-induced constipation, chronic nausea and vomiting, and cannabinoid hyperemesis (p<0.05) were more prevalent in the UK. Cyclical vomiting, functional constipation, unspecified functional bowel disorder, and proctalgia fugax (p<0.05) were more prevalent in the other 25 countries. Diet in the UK population consisted of higher consumption of meat and milk (p<0.001), and lower consumption of rice, fruit, eggs, tofu, pasta, vegetables/legumes and fish (p<0.001). Having a DGBI in the UK and similarly in the other 25 countries, was associated with higher healthcare utilization (more frequent doctor visits, number of abdominal surgeries, and medication use), impaired quality-of-life, anxiety and depression, and somatoform symptom-reporting (p<0.05).ConclusionDGBI are highly prevalent in the UK and worldwide. The national prevalence of Rome IV irritable bowel syndrome and functional dyspepsia in the UK are similar to the global prevalence, highlighting the global consistency and burden of DGBI. However, these data suggest that opioid prescribing, and, cultural, dietary, and lifestyle factors, such as cannabis use, may account for some of the variance in the prevalence of some DGBI between the UK and other countries.

BackgroundStudies from our group have shown that around half of patients presenting with cauda equina syndrome (CES) have normal imaging, many of whom may have evidence of a functional neurological disorder. We have also shown high rates of comorbidity of functional neurological disorders in patients with idiopathic chronic urinary retention (including Fowler's syndrome).AimsTo determine what proportion of patients with ‘scan negative’ CES and chronic dysfunctional voiding have a functional disorder by clinical consensus.To determine distress, disability and ongoing symptoms in patients with ‘scan positive’ and ‘scan negative’ CES three months after symptom onset.To determine frequency of comorbid functional disorders, distress, disability and physical function in patients with voiding dysfunction and a control urological group.Project Plans: The Back or Leg Pain with Bladder symptoms study (BLB) study is a prospective case control study of all patients admitted with possible CES to the Western General Hospital, Edinburgh.The Overview of Comorbidity in Chronic Urinary Retention (OCCUR) study is a prospective cohort study and retrospective notes review of patients with Chronic Urinary Retention (including Fowler's syndrome) via the urodynamic clinics in Glasgow, Edinburgh and London.