The survey included 111 questions, 23 of which were related to the diagnosis of IBS, and 88 on its treatment (Supplementary material 1). The Microsoft Excel® program was utilized for making the calculations, organizing the data, and creating the tables and graphs. For statistical significance, the Fisher’s exact test was used to calculate the p value for a 2 × 2 frequency table. The questionnaire items included questions on the diagnostic criteria utilized, i.e., the Manning, Rome I, Rome II, Rome III, or Rome IV criteria, or if the diagnosis was based on personal experience. The items also asked about the indications for clinical laboratory tests (hemogram, thyroid hormones, CD serologic test, fecal occult blood test, and/or calprotectin stool test) in patients according to IBS subtype, as well as the indications for colonoscopy, abdominopelvic computed tomography (CT), anorectal manometry and/or breath tests for diagnosing small intestinal bacterial overgrowth (SIBO), glucose malabsorption, or fructose malabsorption. Regarding treatment, the questionnaire items asked how frequently dietary treatments (including diets low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols [FODMAPs], low in gluten, and low in dairy products) were indicated and how often medical treatments with antispasmodics, neuromodulators, probiotics, rifaximin, antidiarrheics, and laxatives, as well as psychotherapy and alternative therapies, were recommended. An exploratory, descriptive, observational analysis was carried out on general qualitative data.

Fig. 1 shows the 14 countries the DGBI specialists participating in the survey came from. Over half of them were from Mexico, followed by 11.3% from Argentina, and 7.2% from Chile. A total of 82.5% of the specialists worked in private practices and 17.5% in public healthcare systems.

Fig. 1.

Frequency by country of Latin American gastroenterologists who are experts in disorders of gut-brain interaction (DGBI) who participated in the survey.

The fact that the majority of the specialists surveyed coincided in their use of diagnostic criteria, especially the Rome IV criteria, is important. Even though the use of symptom-based criteria for diagnosing IBS began with the Manning criteria, published in 1978,9 since then, later iterations have been modified with the Rome I criteria, aiming to achieve greater accuracy based on evidence in the medical literature. The Rome IV criteria are the most recent, published in 2016, and they are used not only for diagnosing IBS, but also for other DGBI.1,10 Notably, however, because those criteria were developed for standardizing patients in clinical trials or epidemiologic studies, they have been criticized for their insufficient usefulness in clinical practice. Therefore, the use of clinical criteria has been recommended, that maintains the frame of reference of the Rome IV criteria in general, but with flexibility regarding symptom duration and frequency, especially if the physician feels confident with the results of tests previously carried out on the patient.11 Nevertheless, it is interesting that the Latin America specialists surveyed did use the diagnostic criteria, especially the most recent Rome IV criteria, as a frame of reference for diagnosing IBS. Currently the Rome V criteria are being developed for publication in 2026, and based on them,11 clinical criteria for daily practice will also be recommended.

Given the above, it should be underlined that even though the Rome IV criteria do not specifically require the use of laboratory or imaging tests for IBS, because of the clinical similarity between IBS and other entities, such as CD or inflammatory bowel disease, whether symptoms are due to those other entities or instead coexist with IBS, must be determined.1,12 Some complementary tests, such as hemogram, thyroid function tests, and CD serologic tests, are adequate for the initial evaluation and differential diagnosis of patients meeting the IBS criteria.12,13 In fact, those tests should be adjusted according to the local epidemiology of the abovementioned differential diagnoses, as observed in the present survey. Thus, the experts in Argentina and Chile had a high frequency of indicating a CD serologic test and/or calprotectin stool test, compared with the low frequency for those two tests in Mexico (the country with the highest number of specialists participating in this survey) due to the low prevalence of CD and inflammatory bowel disease in the Mexican population.14,15

Colonoscopy was also reported as the diagnostic tool utilized by the majority of the experts surveyed. It is the method of choice for the prevention and diagnosis of colon cancer. In the present survey, in accordance with previous guidelines, the cutoff point of 50 years of age was used, but current guidelines recommend colonoscopy as screening for colorectal cancer starting at 45 years of age, in subjects with no family history of adenomas or colorectal cancer, and we must ensure that this is being considered in Latin America.16,17 Colonoscopy should also be indicated for all patients with IBS who present with alarm symptoms or changes in bowel habits associated with IBS, regardless of age or IBS subtype. In addition, colonoscopy with biopsy sampling is required in patients with IBS-D who are nonresponders to treatment, to rule out the presence of microscopic colitis, even if there are no apparent mucosal lesions in the colonoscopy, especially in patients above 50 years of age.18–20

An aspect to be emphasized in the present study is the high percentage of the specialists surveyed who reported ordering abdominopelvic CT in patients with IBS criteria. CT is a useful tool in diagnosing vascular, pancreatic, and hepatobiliary diseases, among other organic diseases of the abdominopelvic region.21 However, its use in the digestive tract is more targeted at small bowel evaluation in patients with inflammatory bowel disease, and its performance in patients with IBS tends to be of little usefulness.22,23 Thus, there is no quality evidence justifying the routine use of abdominopelvic CT in patients meeting the IBS criteria, in whom there are no signs suggestive of organic disease.23 Perhaps this was due to the manner in which we formulated the question in our survey, making it unclear to the responders that CT was carried out to explain patient symptoms when intra-abdominal malignancy was suspected. Nevertheless, that datum provides an educational opportunity for physicians, and knowing the response of internists and general practitioners would be interesting.

Anorectal manometry in IBS-C was considered a useful test for categorizing patients with symptoms suggestive of a defecatory disorder, by the majority of the specialists surveyed, given that it enables the diagnosis of inadequate defecatory propulsion and/or dyssynergic defecation.24,25 The performance of anorectal manometry in patients with IBS-C who have reduced stool frequency could be a useful alternative, when there is not a good response to medical treatment.26 Importantly, anorectal manometry is also useful in fecal incontinence exacerbated by the presence of diarrhea, as presented in IBS-D. However, our survey had the limitation of only investigating its use in IBS-C. The finding that anorectal manometry was more frequently ordered by experts working in the public healthcare system than by those with private practices may be related to the large investment having this technology entails; therefore, it is more likely available at a public healthcare hospital center. This is another aspect that we should study in more detail in the future.

SIBO, lactose malabsorption, and fructose malabsorption are conditions that are frequently associated with IBS.27–31 Even though the gold standard for diagnosing SIBO is duodenal fluid aspiration, for determining the count of bacterial colony-forming units, the difficult reproducibility of the procedure impedes its routine use, which is why a presumptive diagnosis is frequently made through symptom identification or a breath test.27,28 Studying patients by means of a breath test is also done when sugar malabsorption is suspected. Nevertheless, the lack of agreement in the protocolization of those tests, the variability in result interpretation, and test availability in different countries appear to influence the frequency with which breath tests are ordered.27–31 We found that the experts from Argentina and Chile ordered breath tests more frequently, and despite the fact that the AGA guidelines do not recommend their routine use in diagnosing IBS, local conduct in those two countries appears to give much importance to that potential pathophysiologic aspect of IBS.32,33 In contrast, the Mexican consensus on IBS indicated there was insufficient evidence for recommending the routine use of breath tests for SIBO,7 concurring with the lower frequency with which the gastroenterology specialists in Mexico ordered them, at only 54% (data not shown). Nevertheless, 80% of those experts indicated them “sometimes”. Results were similar for the specialists from Brazil, Colombia, Honduras, and Paraguay, who “never” ordered them, whereas those from Bolivia, Guatemala, Nicaragua, Peru, and Uruguay “sometimes” ordered them (data not shown).

With respect to treatment alternatives, diet was a frequently indicated option by the Latin American specialists. The low FODMAP diet was initially considered an empiric resource, but there is now more evidence that, despite its significant efficacy in improving symptoms, it appears to be highly restrictive, and so, should be guided by a specialist in nutrition. Its superiority is not clear, when compared with other diets.34 Utilizing diets based on individual patient tolerance may be an effective option and easier to correctly carry out than the low FODMAP diet. Gradual re-introduction of restricted foods should be attempted, once symptoms have improved.35

As expected for our region, antispasmodics were the most widely used treatment by the experts surveyed and the findings coincide with the recommendations of the position statement of the AMG, on the treatment of IBS.8 Those drugs are frequently indicated for treating abdominal pain in IBS due to their efficacy and safety profiles, which has made them a very attractive therapeutic alternative.36 Even though the most widely used antispasmodic in our survey was trimebutine (alone and combined with dimethicone), according to current publications, pinaverium bromide appears to be more effective for abdominal pain control, and its combination with dimethicone may be useful in controlling bloating. Nevertheless, there is insufficient quality evidence for categorically recommending it over other antispasmodics.37,38 Limitations are based on local availability of the different antispasmodics. In fact, the reason they are not recommended in international guidelines, such as those of the ACG, is precisely due to the lack of high-quality clinical trials on this group of agents, especially on the antispasmodics available in the United States.3

The frequent use of central neuromodulators by the Latin American specialists was an important finding, contradicting the adverse connotation these medications have, especially for patients, and the fact that they are not covered by insurance companies for their use in IBS and other DGBI. This is in contrast with other parts of the world, where they do have insurance coverage, but are not used as frequently. Neuromodulators are a second-line alternative for managing IBS symptoms, regardless of the presence of psychiatric comorbidity.39 The most solid evidence is on tricyclic antidepressant use in abdominal pain control; they should be utilized with caution in patients with constipation and in advanced age patients.39,40 In many cases these drugs can be used as first-line treatment. SNRIs, particularly duloxetine, are also a highly effective option for pain control, albeit with lower quality evidence.39,41 SSRIs are apparently not effective in abdominal pain control and have only shown efficacy in controlling symptoms of depression and anxiety.39,40 There is very limited evidence on the use of benzodiazepines and peripheral neuromodulators, such as delta ligands, in IBS,42 with the exception of the Rome Foundation’s recommendation as part of augmentation therapy, if control with tricyclic antidepressants, SSRIs, SNRIs, and tetracyclic antidepressants is not achieved.43 Following the abovementioned recommendations, 50% of our experts indicated neuromodulators.

There appears to be excessive use of probiotics for IBS, given that there is no strong evidence for it. Even though meta-analyses and systematic reviews have concluded that probiotics are superior to placebo in IBS, the existing trials do not distinguish between the species and strains used, hampering their indication.44 In the meta-analyses that actually have differentiated between species, multispecies probiotics that combine bifidobacteria and lactobacilli appear to be advantageous in the treatment of abdominal pain, overall symptom improvement, and bloating, but the evidence is not conclusive for categorically preferring them over other formulations.45 This is another aspect that provides an educational opportunity in Latin America, given that it is important for physicians in charge of managing patients with IBS to be familiar with the differences in each probiotic, understanding that every species does not produce the same results.46

Rifaximin is a nonabsorbable antibiotic that is indicated as treatment for different manifestations of IBS due to its anti-inflammatory action and its benefits in promoting intestinal eubiosis.46,47 In the present survey, it was presented as an alternative, mainly utilized in patients with diarrhea and abdominal distension. Due to its cost-effectiveness in Latin America and short treatment duration, it is an alternative that can be tested empirically in IBS patients with constipation and in those with abdominal distension. On the other hand, rifaximin is the treatment of choice for SIBO, a condition often associated with IBS. Thus, it may be considered the treatment of choice in patients with IBS that have a positive breath test for SIBO.28,48 However, the above information does not mean that treatment with rifaximin in IBS-D, IBS-M, or for abdominal distension should be contingent on a positive breath test for SIBO. In fact, that breath test is not available in the majority of Latin American countries, and when it is available, could end up costing more than the test treatment with rifaximin. Therefore, rifaximin may be used empirically in IBS when SIBO is suspected.49,50

The survey respondents also showed an inclination to utilize different alternatives for the specific management of diarrhea and constipation. Of those options, cholestyramine has shown efficacy in the management of diarrhea due to bile acid malabsorption, a condition present in 30% of cases of IBS-D,51 but the drug is not well tolerated by patients. Although today there are noninvasive tests, such as 7-alpha-C4, to screen for the presence of bile acid malabsorption, that test is still costly and unavailable in most Latin American countries, making the empiric prescription of cholestyramine an alternative.52

Regarding modern treatments for IBS-C, such as secretagogues, good quality evidence on linaclotide has shown efficacy in pain control and stool frequency in patients with IBS-C,53,54 but it is only marketed in some Latin American countries. The same is true for lubiprostone, which is only used when available. Prucalopride has been evaluated with favorable results in the treatment of constipation due to slow bowel transit.55 Even though there are no studies on patients with IBS-C, the drug could be considered an alternative for increasing stool frequency in those patients. In fact, in the recent position statement on the pharmacologic treatment of IBS by the AMG, prucalopride was recommended as an adjuvant in the management of IBS-associated constipation.8

Lastly, psychotherapy and alternative therapies were considered by a high percentage of the experts surveyed. These options have gained ground in the treatment of IBS and other DGBI, largely due to the increase in publications favoring their use as a resource in patients who do not respond to conventional treatment.56 However, specialists in these therapies are not necessarily available to patients with DGBI, which can limit their use. In fact, evidence suggests that the results in therapies administered by professionals are significantly superior to those that are self-administered by patients, reinforcing the concept of the importance of maintaining a good doctor-patient relationship in these types of disorders.57

The present study has certain limitations. For example, the use of medications, such as ondansetron for IBS-D, was not investigated. In addition, certain symptom characteristics were not specified, such as whether abdominal distension was objective, subjective, or both. It would also have been interesting to know the age and sex of the experts surveyed to evaluate if there were differences in the diagnosis and treatment of IBS related to those factors. Another limitation was the low level of participation of specialists in the majority of the countries in Latin America. Greater participation would have enabled more specific comparisons in the diagnosis and treatment of IBS, but at the same time, the low participation is a reflection of a lack of specialists in DGBI in those countries. Another limitation was the fact that there were no questions asking about how low FODMAP diets, apparently widely utilized in the region, are indicated, to know if there was a total restriction of FODMAPs for 6 weeks, followed by the progressive reintroduction of each food, for detecting which foods were not tolerated by each patient, as well as if a nutritionist guided the diets of the patients.34,35 We, the authors of this survey study, are of the opinion that the low FODMAP diet is not being properly carried out, which needs to be investigated and turned into an educational opportunity. Despite its limitations, the results of this survey enable us to have a general understanding of how Latin American gastroenterologists, who are specialists in DGBI, diagnose and treat IBS.