Common Misconceptions, Missed Opportunities in the Management of Irritable Bowel Syndrome

Overcoming misconceptions and controversies about irritable bowel syndrome are key to improving the care of patients with the common yet often misunderstood gastrointestinal disorder, according to a new study co-authored by a leading Houston Methodist Hospital expert on digestive health.

The study, published in Nature Reviews Gastroenterology & Hepatology, aims at helping clinicians better implement findings from decades-long research that has increased the understanding of IBS' pathophysiology. Despite such progress — IBS is now recognized as a disorder of gut-brain interaction rather than simply a "functional" condition — many physicians still struggle with outdated practices.

"For too long, irritable bowel syndrome has been labeled a diagnosis of exclusion," said Dr. Eamonn Quigley, co-author and chief of Houston Methodist's Underwood Center for Digestive Health. "However, the evidence is clear: a positive diagnostic approach using established criteria is safe, cost-effective and more reassuring for patients. We need to stop sending patients through unnecessary tests that add little value."

IBS, which causes gas, abdominal pain, diarrhea and constipation, affects an estimated 5% to 10% of the global population. It can be managed, but there is no known cure.

The article cautions against overreliance on unvalidated commercial microbiome tests to inform treatment and hydrogen breath testing for small intestinal bacterial overgrowth. Both practices, Dr. Quigley and his co-authors emphasize, lack the clinical precision to guide treatment.

"There's a real danger when patients spend money on tests that provide no actionable insights," Dr. Quigley said. "It puts clinicians in a difficult position and risks undermining trust. Until we have validated biomarkers, diagnosis should be based on careful history, limited testing and clinical judgment."

Dietary strategies, particularly the low FODMAP diet, can help some patients but should not be considered first-line therapy. Dr. Quigley urged caution, citing risks of nutritional deficiencies and the psychological burden of overly restrictive diets.

"The low FODMAP diet is not a cure-all," he said. "It must be implemented with the guidance of trained dietitians, and not at the expense of a patient's long-term health."

The review also highlights the role of gut–brain neuromodulators and behavioral therapies such as IBS-specific cognitive behavioral therapy and gut-directed hypnotherapy. Dr. Quigley argued these strategies should be introduced earlier in the treatment pathway, rather than reserved for refractory cases.

Access to effective drug therapies remains another challenge, with medications such as linaclotide and alosetron available only for certain patients, in certain countries.

"We need to recalibrate our perception of treatment risk and align it more closely with our patients' willingness to accept those risks in order to achieve relief," Dr. Quigley said.

By advancing evidence-based strategies and correcting misconceptions, Dr. Quigley and colleagues hope to reframe perceptions of IBS while reshaping clinical management of the condition.

"The ultimate goal is personalized therapy for every patient," Dr. Quigley said. "That requires moving beyond outdated paradigms about irritable bowel syndrome and embracing a biopsychosocial model that reflects the true complexity of this condition."

The Nature Reviews article was co-authored by Drs. Cristopher Black and Alexander Ford of Leeds Gastroenterology Institute and Dr. Carolina Olano of Universidad de la Republica in Uruguay.