An Evidence-Based Systematic Review on the Management of Irritable Bowel Syndrome

Section 2.1 Methodology for systematic reviews of irritable bowel syndrome therapy, levels of evidence, and grading of recommendations We have conducted a series of systematic reviews on the diagnostic criteria, the value of diagnostic tests, and the efficacy of therapy in IBS. We also performed a narrative review of the epidemiology of IBS. There have been several systematic reviews of therapy for IBS (1-5), but these either have not quantitatively combined the data into meta-analyses (1-3) or have inaccuracies in applying eligibility criteria and data extraction (4,5). We have, therefore, repeated all systematic reviews of IBS and synthesized the data where appropriate. Systematic review methodology For all reviews, we evaluated manuscripts that studied adults using any definition of IBS. This included a clinician-defined diagnosis, Manning criteria (6), the Kruis score (7), or Rome I (8), II (9), or III (10) criteria. For reviews of diagnostic tests, we included case series and case-control studies that evaluated serologic tests for celiac sprue (anti-gliadin, anti-endomysial, and tissue transglutaminase antibodies), lactose hydrogen breath tests, and tests for small bowel bacterial overgrowth (lactulose and glucose hydrogen breath test or jejunal aspirates). For reviews of therapies of IBS, we included only parallel group RCTs comparing active intervention either or and and therapy therapy therapies therapies and therapies for or of the of IBS or or IBS or for of studies and the of the IBS the irritable bowel syndrome and and and IBS, irritable and a for that of bowel combined the therapies for and the and and and and the and therapy, therapy, and and and the therapy, therapy, and or and the of the of also and and of that not for data extraction and in the for on studies and for of of of of and of the of studies the a score of a and data the and a on using a and any of IBS a the not in of of IBS not combined using the and of also the test of the for in or in or of small evaluated using tests for the of the the and using the Methodology for levels of and grading recommendations for grading recommendations in the of and the of This in the of of and in the grading recommendations or the of and on the of or the of the of and and of the or not recommendations and or not recommendations in the of recommendations a that in and in the of the of the a only data of IBS therapies have not been studied in of IBS therapy a for IBS and for and in the not of of irritable bowel syndrome IBS a and that a and on criteria, of have IBS data that and and that IBS in in in and in of IBS the diagnostic tests, have and IBS. in and the of and IBS a that and of and of several For that have IBS, and that IBS not or For that IBS a of and of the of IBS on and on and For and that IBS a and a a and that or For and the and IBS, and a that IBS of review data the of of IBS, the of IBS and the of and of the of IBS on and the of IBS, and and systematic reviews have the of IBS in and This that IBS of all on several the definition Manning criteria Rome the of the and the methodology and of the the we performed systematic review studies that only Rome the not or and included not not IBS in or in We studies and that IBS and a of reviews that IBS the and the of IBS in that IBS the that IBS There several of IBS, and of IBS in in IBS not a of IBS a of the a in the IBS in the of in of the group also the data that the for IBS in but that of all IBS. review studies that IBS of a in IBS of the diagnosis, only of studies have in IBS and in or these have been in a systematic review that IBS score on all of the IBS have the and a have or on the in IBS in and This in the of IBS and of of these performed in and the and in these not that IBS and also that IBS the of that IBS and IBS also a on and the and in IBS, we that for in IBS the of IBS and of in IBS and of in that a and of and into a of in IBS several studies have of in IBS the of the of the bowel several studies that in IBS, in parallel not only the of IBS, but also data that in IBS the of and the of and that in and a of and in and that these of and for not the of of or or that on of and and and in IBS. bowel in IBS but not the of IBS and the in IBS a of of studies that for IBS in the and that IBS in and IBS IBS data that the of IBS not only the of the but also the of IBS a of in the of data that diagnostic tests and in IBS Section the and of these data of the of in IBS diagnostic tests, and For IBS that IBS the of performed in of for IBS of data that a diagnostic in IBS, and that not and not in IBS also the of in of IBS that the a of that in several and diagnostic tests in of the There a and levels of and the of diagnostic in IBS, that for in IBS, and or diagnostic tests of IBS of a of and on the IBS of the and of the that of of IBS have and and the of bowel not that in IBS that and also the and bowel and the in bowel the in the Section of diagnostic criteria in IBS IBS or that in bowel a of have for IBS therefore, the a diagnostic criteria have for IBS, criteria, Kruis and Rome I the of Rome II and Rome III criteria not been conducted a systematic review of the of criteria in the of IBS studies all IBS a that included either a or a of in studies or and all in IBS. the but the but of criteria have been a of IBS of diagnostic criteria irritable bowel of Manning and have been studies the of criteria in studies these criteria performed in the studies criteria a of and of of criteria Kruis and studies have the of in studies the Kruis score value a of and of group the Rome criteria, have criteria have been been only in the of Rome I criteria been evaluated and the of Rome II or III the the Rome I criteria a of and of studies the of diagnostic criteria in IBS the of of a test for of the diagnostic criteria have and the Rome criteria, in have been in the that a definition that and that of diagnostic criteria therefore, IBS or that in bowel a of Section of in the of IBS the diagnostic of and value in IBS and have for in criteria of IBS, the of and a of bowel or celiac the that the of IBS IBS also that and a of and celiac that of been in a systematic review of the This review evaluated all that IBS a the of review IBS or the of of a of studies the diagnostic of in the and the for the of the and the of the of review on the of studies and on the of in a of and of for studies evaluated the diagnostic of and a of and of for in There studies that the of in a of and of also been that the of a group of that in in in IBS There that a of and celiac sprue of these of of There of a of in of also that and of have celiac sprue the of and value in IBS and have for in criteria, the of and a of or celiac the that the of IBS Section of diagnostic in IBS diagnostic for and and not in IBS and of a of serologic for celiac sprue in and breath lactose a data breath for small bacterial overgrowth in IBS of the of and not in of IBS and performed in IBS and in the of for the of performed in IBS a of for not tests performed that IBS in the and the that the of IBS and of the for IBS of IBS of IBS IBS a of This for and that IBS a of diagnostic tests and IBS review the value of diagnostic tests in IBS, of for celiac breath for lactose and bacterial and on the of a diagnostic test in a IBS the of the in the of a diagnostic that either or also the and of the diagnostic test on systematic reviews that the of in IBS in of in criteria for of the data a of the small of the the of and of that or these the of and not in IBS There evidence, that celiac sprue and lactose in IBS in a of IBS but the diagnostic criteria for IBS and have the of IBS. of and and in IBS in studies have evaluated the of in IBS of tests a value that in the in the in test have been the and the IBS not been For these the of tests in IBS not for and value in the of IBS and have evaluated the of and in IBS of IBS and a in in of not not on these the not the of and in IBS. There data on the of tests in IBS. evaluated the of or in IBS the Rome I criteria these the of in the a of the of IBS. the of in IBS and There evidence, that the of celiac sprue IBS in systematic review performed for case-control studies of or for celiac of the IBS of have a or transglutaminase or a of studies of IBS of have serologic (anti-gliadin, anti-endomysial, transglutaminase and small bowel of celiac sprue have evaluated the of serologic for celiac sprue in IBS and that the of celiac sprue on the of evidence, the for celiac sprue in and on data studies of IBS the systematic review performed for the of lactose lactose breath a of data case-control studies lactose in IBS in these not lactose and IBS that a of IBS have in and that the of lactose in IBS in For these the that a lactose and IBS a and review of a the of lactose of a lactose hydrogen breath test and or IBS of been on the of in the of IBS and glucose breath have the systematic review performed for included studies and IBS the of a breath test using glucose breath studies and glucose breath the of a the only performed that breath glucose breath and jejunal for in the of test IBS and in small bowel that not the diagnostic for in the IBS that the and a in the of a of IBS the breath for in IBS. diagnostic tests have been evaluated in IBS and for of in IBS test and been of have been in the of in IBS a in IBS and in in or levels also in the the of these tests in IBS in IBS that the a systematic included studies and a of IBS or or in a that the of in or and in the of or of and in the IBS in the the and of in the IBS on these the that any of IBS for the of of not have not IBS also or the that in a IBS and where the IBS also have the and of the and the of diagnostic and tests on that of the and of in of a the of in and of and in and of IBS all of the the a that also and the that a a of a that or a a of IBS and the for the of small bowel for celiac sprue or for have the of the of or for the of IBS been the of the studies of for Section and irritable bowel syndrome IBS There that or in IBS and of a not IBS that that of IBS that and also have intervention in IBS. the a and that have all and data the of all these in the systematic review of the on in IBS studies the of IBS studies and the of these that the efficacy of in IBS, a that the that in of irritable bowel syndrome test tests and or levels have been but all have and that have evaluated in IBS have the of and the of tests This of either a of of the diagnostic test or that not a of IBS of the and that a of the the in of the evaluated the efficacy of on levels a of IBS test and or a that the of the or that the only of in the group of in the not have efficacy in in IBS, a in of bacterial in or that the in a the for the of IBS, a these RCTs celiac sprue and lactose Section of and in the of irritable bowel syndrome and a or in the of of IBS and for not small in the of or bowel and in IBS. of the systematic review RCTs but conducted of therefore, small and a of and in only of these only and in the of the studies not IBS studies not diagnosis, or in and in and the of studies we the of or a in IBS. not a in and the the of IBS not IBS in of the studies of IBS not of the of in IBS IBS in and not in these studies of studies and that and these have not been studied in in adults IBS and have been studied in small and in of bowel bowel but on Section of in the of irritable bowel syndrome and of in IBS for efficacy not for and in IBS, on a small of studies on evidence, been that IBS in of on and on therefore, have been and in IBS the the that these have been and systematic review that for the efficacy of a in IBS, in the of these in For of the studies using and that not in the and a of and the of in that in the of the and in of diagnostic criteria a of the Rome criteria, of therapy, and of only studies and only a in IBS therapy data also not of a of or a for only studies on of IBS and the of studies a of included IBS and the of IBS in all the data for and have in IBS, the all the of IBS There only a small of for efficacy for the of the efficacy of studied in and of the of these not been studies on the of in and and in either in any of the of studies of of and and have been for on a for the of data the of in the studies in a systematic review comparing in all but and only on the of IBS of IBS studies IBS studies data and these in Section of in the of irritable bowel syndrome not or of IBS, but for of and RCTs have not been and data on IBS have therefore, that in the only evaluated in RCTs for the of IBS. There have been RCTs that evaluated the of in the of IBS There of on of IBS not but of of of in a of IBS the that of the group of of that the of not There in and in of the Section of in the of irritable bowel syndrome of a for of IBS and for There data the and of for the of IBS a efficacy in RCTs IBS of these RCTs all criteria for RCTs studies of of of and and criteria of the Rome for of of Rome criteria for IBS, of IBS and in IBS of these RCTs in and in IBS or not for of IBS, for of the of for IBS of for for for and for only and in in on these in or IBS a of and the for the for for for of IBS in of the a of the not of the of a IBS for or a of IBS on a and a in IBS of a on of the in and a of the data not for the of or a of of Rome II criteria for IBS. IBS that have the of but the of that have the of in This that of IBS not of RCTs have that IBS for hydrogen breath tests, for breath tests and tests in a of and and of breath tests in and on on IBS repeated of a of that in IBS of not efficacy of for IBS a a of for for and or for of also and and IBS of or Manning criteria. IBS of the group and of the group IBS of that IBS but not data that on but all that data on and in and in IBS and in of in in or IBS of for IBS on a for IBS for but also efficacy in a small of IBS not in the and of IBS and the any a or of in IBS also that data on on II III studies have Section of in the of irritable bowel syndrome not and of efficacy have been on for in the of IBS, in the of the and and of in IBS and in the and levels of or have studies of the of these in IBS. systematic review studies a of that of studies of and of of but Rome or Manning criteria. evaluated and IBS a a a IBS in group of data the of and of of small studies in the studies a There the of and of all a IBS a a IBS evaluated in and on IBS evaluated of in a in IBS evaluated in a IBS of review that a of and of therefore, a the in IBS. review data that all therapies a for in IBS. the data have on in IBS and a for IBS review we a all of of a in the on that the in the of and This included in the but been the data have all and and the not have in the data that the active in that of in a on IBS. 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There RCTs either or studies a of for therapy and of We of in Rome II IBS of for a of and of of that of for of III that only the for the of IBS of in a and that the efficacy not of in only There of and of the and of the in the in the RCTs in of the group and of the of of the in data the of RCTs the There and the of and in of of or a not any but the and have been in using that levels the that and a of these the in but a the efficacy for IBS and IBS in on only the not of of III the of for the of IBS not Section of the in the of irritable bowel syndrome in a of in IBS in the only the into the into the that in the the of a of in the in the small the the in the of the and the of of a of into the of the of the a into the of for a that the of and have been of in not into the and in the small also or efficacy in RCTs in a of of into in and of in studies in in the the for in RCTs studies a on a for of or for of and not of and not have any of or for of for the III studies only a of in these studies only for in the in for the that in the of also in these in of and studies of the III in the in the the the either on therapy or therapy and for There in and the of This that of and studies and of of studies using in of all II and III studies using in for that the and and also in of for in and in the in III studies of and included and and of the and in of and in of in the been a studies and of of and the that have have a test therapy and and There of in a of and that evaluated Section of in the of irritable bowel syndrome and IBS and There data on the and of these in IBS IBS that for a the data on efficacy of in IBS, been the in IBS of included IBS a and the Rome I criteria for IBS. a of a and for a of of of on in the definition of a on a of the on a and not the and of of the of that a in of the that of the evaluated not IBS of not therapy a a of the of in IBS of efficacy been systematic review on in that in IBS, but data on not included a in IBS and have on the that of For been 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studies of these studies the group and therapy therapy and therapy all studies evaluated the efficacy of in IBS and a of IBS not that not included in the efficacy not also the data that of the of therapy in of of the any therapy therapy, and a all studies in a therapy in IBS not been of the of of or the of the the of therapy, and the and of the Section of therapies and in the of irritable bowel syndrome systematic review of therapy in IBS been the RCTs the for in and a not these studies into a and any of therapy in IBS the and also the of and also of any systematic review of that and the review that the efficacy of intervention any recommendations on or therapy Section therapies for the irritable bowel syndrome of the of IBS the of a of in of This on that have the of of and and for the in the of of and of the and of and conducted in small of and and the and of the the and of and the and of the in or that of and the efficacy and of a of the of the the of efficacy and for that the efficacy and of the in the of for of the and the a of in all and for of and on the of a in and the in that and also and for the of adults and in in and of and efficacy in for and into the of and of a a for and been and of in a of data a and of for for and III studies in the the of the and efficacy in a of adults in adults in and of on a in IBS a in or and in a in for of a bowel in and been for the of This a of in the of a that in the of several and efficacy in IBS in the and in for IBS. the in the efficacy of in a evaluated a for a of the of of IBS for of been in a all a for of IBS and not been a small of have been There for of in the and in of have in the of a and in and in bowel a the of and in the of bowel and in bowel and of a bowel in the This also a for a for the of IBS in a in in the and efficacy of in a and studies have in and in in of the of the and in IBS the and of the in a small of IBS of the in a group of have not been evaluated in a in IBS There that of in of IBS have in 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