Functional bowel disorders with diarrhoea: Clinical guidelines of the United European Gastroenterology and European Society for Neurogastroenterology and Motility

United European Gastroenterol J. 2022 Jul;10(6):556-584. doi: 10.1002/ueg2.12259.Epub 2022 Jun 13.


Edoardo Savarino 1Fabiana Zingone 1Brigida Barberio 1Giovanni Marasco 2 3Filiz Akyuz 4Hale Akpinar 5Oana Barboi 6 7Giorgia Bodini 8Serhat Bor 9Giuseppe Chiarioni 10Gheorghe Cristian 11Maura Corsetti 12 13Antonio Di Sabatino 14Anca Mirela Dimitriu 15Vasile Drug 6 7Dan L Dumitrascu 16Alexander C Ford 17 18Goran Hauser 19Radislav Nakov 20Nisha Patel 21Daniel Pohl 22Catalin Sfarti 6 7Jordi Serra 23 24 25Magnus Simrén 26Alina Suciu 15Jan Tack 27Murat Toruner 28Julian Walters 29 30Cesare Cremon 2 3Giovanni Barbara 2 3


Author information

1Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy.

2Division of Internal Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.

3Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.

4Department of Gastroenterology, Istanbul University Istanbul School of Medicine, Istanbul, Turkey.

5Department of Internal Medicine, Dokuz Eylül University School of Medicine, Izmir, Turkey.

6Department of Gastroenterology, 'Grigore T. Popa' University of Medicine and Pharmacy, Iasi, Romania.

7Institute of Gastroenterology and Hepatology, 'Saint Spiridon' Hospital, Iasi, Romania.

8Gastrointestinal Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy.

9Division of Gastroenterology, Ege University School of Medicine, Izmir, Turkey.

10Division of Gastroenterology, University of Verona, Verona, Italy.

11Fundeni Clinical Institute Center of Gastroenterology and Hepatology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.

12National Institute for Health Research, Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK.

13Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK.

14First Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, University of Pavia, Pavia, Italy.

15Center of Gastroenterology and Hepatology, Fundeni Clinical Institute, University of Medicine and Pharmacy, Bucharest, Romania.

162nd Department of Internal Medicine, 'Iuliu Hatieganu' University of Medicine and Farmacy, Cluj-Napoca, Romania.

17Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK.

18Leeds Institute of Medical Research at St. James's Sciences, University of Leeds, Leeds, UK.

19Department of Gastroenterology, Clinical Hospital Center Rijeka, Faculty of Medicine, University of Rijeka, Rijeka, Croatia.

20Department of Gastroenterology, Tsaritsa Yoanna University Hospital, Medical University of Sofia, Sofia, Bulgaria.

21Imperial College Healthcare NHS Trust, Institute of Global Health Innovation, St Mary's Hospital Campus, London, UK.

22Department of Gastroenterology, University Hospital Zurich, Zurich, Switzerland.

23Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Badalona, Spain.

24Digestive System Research Unit, University Hospital Vall d'Hebron, Barcelona, Spain.

25Department of Medicine, Autonomous University of Barcelona, Badalona, Spain.

26Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.

27Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium.

28Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey.

29Division of Digestive Diseases, Department of Metabolism, Digestion, and Reproduction, Faculty of Medicine, Imperial College London, London, UK.

30Department of Gastroenterology, Division of Medicine and Integrated Care, Imperial College Healthcare NHS Trust, London, UK.


Irritable bowel syndrome with diarrhoea (IBS-D) and functional diarrhoea (FDr) are the two major functional bowel disorders characterized by diarrhoea. In spite of their high prevalence, IBS-D and FDr are associated with major uncertainties, especially regarding their optimal diagnostic work-up and management. A Delphi consensus was performed with experts from 10 European countries who conducted a literature summary and voting process on 31 statements. Quality of evidence was evaluated using the grading of recommendations, assessment, development, and evaluation criteria. Consensus (defined as >80% agreement) was reached for all the statements. The panel agreed with the potential overlapping of IBS-D and FDr. In terms of diagnosis, the consensus supports a symptom-based approach also with the exclusion of alarm symptoms, recommending the evaluation of full blood count, C-reactive protein, serology for coeliac disease, and faecal calprotectin, and consideration of diagnosing bile acid diarrhoea. Colonoscopy with random biopsies in both the right and left colon is recommended in patients older than 50 years and in presence of alarm features. Regarding treatment, a strong consensus was achieved for the use of a diet low fermentable oligo-, di-, monosaccharides and polyols, gut-directed psychological therapies, rifaximin, loperamide, and eluxadoline. A weak or conditional recommendation was achieved for antispasmodics, probiotics, tryciclic antidepressants, bile acid sequestrants, 5-hydroxytryptamine-3 antagonists (i.e. alosetron, ondansetron, or ramosetron). A multinational group of European experts summarized the current state of consensus on the definition, diagnosis, and management of IBS-D and FDr.


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