New Rome consensus: IBS-like symptoms in IBD remission

IBS-like symptoms affect about 1 in 3 people with IBD, and a new Rome Foundation consensus recommends offering brain-gut behavioral therapy early, not as a last resort.¹ For patients in confirmed remission, that means managing the predominant symptom rather than escalating IBD therapy on symptoms alone.¹

That guidance gives a name and a pathway to a presentation most GIs know well: a normal calprotectin, a quiet scope, and persistent abdominal pain, urgency, or bloating.

Until now, the next step came down to individual judgment. You could escalate a biologic, add a symptom-targeted drug, refer to a dietitian, or bring in gut-brain therapy.

The consensus, from a 13-member international panel and published in Gastroenterology, rated 86 of 105 statements appropriate.¹ Here's what it means in practice, and where gut-brain therapy fits.

How common are IBS-like symptoms in IBD remission?

IBS-like symptoms affect 30.3% of people with IBD, according to pooled data in the consensus.¹

An earlier meta-analysis of 3,169 patients in remission found a similar rate of 32.5%.²

The rate depends on how remission is defined, which is why objective confirmation matters:²

Even with endoscopic remission, roughly 1 in 4 patients still has IBS-type symptoms. That's too many to manage by escalation alone.

How the Rome Foundation consensus defines IBD with IBS-like symptoms

"IBD with IBS-like symptoms" is the consensus term for abdominal pain, altered bowel habits, or bloating in Crohn's disease or ulcerative colitis that isn't explained by active inflammation or structural disease.¹ The panel rated the term appropriate, with a median score of 8 out of 9.¹

The term moves the conversation beyond "is this a flare?" It gives you language for a patient who has both an inflammatory disease and a gut-brain disorder pattern.

How to confirm IBD remission before attributing symptoms to IBS

The consensus recommends Rome clinical criteria plus objective exclusion of inflammation with biomarkers and endoscopy, both rated 9 out of 9.¹ Radiologic assessment in ulcerative colitis was rated uncertain.¹

Small bowel Crohn's disease needs particular care:

“Fecal calprotectin can also be normal in small bowel disease. So you can see how this diagnosis could be missed with a more cursory evaluation.”

– Dr. Emily Ward, Gastroenterologist, Founder of GutsyRX

Applying this in practice

Confirm that remission is objective, not only symptomatic, before you label symptoms as IBS-like. A normal calprotectin in a symptomatic patient with Crohn's disease may still warrant endoscopy or imaging if the clinical picture doesn't fit.¹

Persistent diarrhea also needs a workup for other causes. The consensus algorithm includes bile acid malabsorption among them.¹

Why the consensus advises against escalating IBD therapy for symptoms alone

Immunomodulatory therapy should be escalated only with objective evidence of active inflammation, not symptoms alone, the consensus recommends.¹ If inflammation is active, optimize IBD therapy. If it isn't, or it's too mild to explain the symptoms, manage the predominant IBS-like symptom.

Clinical judgment still applies. The panel rated individualized decisions on inflammation thresholds 9 out of 9.¹

What the consensus adds is a clear rationale to pause before stepping up a biologic for abdominal pain with a normal scope.

IBS-like symptoms in IBD: treatment options rated by the Rome consensus

Diet, symptom-targeted medications, and brain-gut behavioral therapies were all rated appropriate, with brain-gut behavioral therapies scoring highest.¹ These are the median panel ratings on a 9-point scale, where 7 to 9 is appropriate:¹

Diet has a narrower role. In a randomized trial in quiescent IBD, 4 weeks of low FODMAP advice gave more patients adequate relief than a control diet (52% vs 16%), but the change in IBS-SSS wasn't statistically significant.³

The diet also lowered fecal Bifidobacterium species.³ Our dietitian's guide to IBS symptoms in IBD remission covers reintroduction in more detail.

Applying this in practice

Choose by predominant symptom, bowel pattern, and anatomy. In Crohn's disease, check for strictures before recommending psyllium or a 5-HT4 agonist, because the panel's rating depended on there being none.¹

If a patient has already cut out multiple foods, involve a GI dietitian before any further restriction.

Where gut-directed hypnotherapy fits for IBS-like symptoms in IBD

Brain-gut behavioral therapies scored 9 out of 9 with no panel disagreement, and the consensus recommends bringing them in earlier rather than holding them as a last resort.¹ GI-focused CBT also scored 9, and gut-directed hypnotherapy scored 8.¹

The evidence extends to IBD itself. In a randomized trial in quiescent ulcerative colitis, 68% of patients who had gut-directed hypnotherapy stayed in remission for 1 year, compared with 40% of controls.⁴

The panel also rated a strong clinician-patient relationship, including a patient-centered explanation of the brain-gut axis, 9 out of 9.¹

Access is the practical barrier. GI psychologists are scarce in much of the US, so a referral for brain-gut behavioral therapy can mean a long wait.

“NERVA is positioned as an adjunct for those seeking support alongside IBD care. So it's not a treatment for active inflammation, but it can target the functional gut-brain symptoms such as pain, urgency, and bloating that persist in many of our IBD patients, even when they're in histologic remission.”

– Dr. Stephanie Moleski, Gastroenterologist, Associate Professor of Medicine at Thomas Jefferson University, Medical Director of the Jefferson Celiac Center

Where a digital gut-brain therapy program fits for IBD patients in remission

Nerva is a 6-week digital gut-brain therapy program, delivered via an app in 15–20 minutes a day. It combines gut-directed hypnotherapy with CBT-informed education and breathing exercises.

It works alongside the IBD care you already provide and isn't designed to manage active inflammation.

In a DDW 2026 abstract, Nerva users who reported Crohn's disease (n=100) or ulcerative colitis (n=151) had abdominal pain responder rates (≥30% improvement) of 52% and 60%, compared with 58% in users with no co-morbid GI condition (p=0.26).⁵

Psychological improvements on the PHQ-4 were similar across groups.⁵ IBD status was self-reported, so controlled studies are still needed.

In IBS, the evidence is peer-reviewed and randomized. In an RCT of 244 adults with IBS, 81% of Nerva participants achieved a clinically meaningful improvement on the IBS Symptom Severity Scale, compared with 63% on an active control.⁶

In the same trial, 71% had a clinically significant reduction in abdominal pain, compared with 35%.⁶ The ACG clinical guideline also suggests gut-directed psychotherapies for global IBS symptoms.⁷

A randomized trial with Monash University researchers is now recruiting. It compares Nerva with psychoeducation in people with quiescent IBD and persistent IBS-like symptoms.

You can refer gut-brain therapy patients through the clinician form or simply recommend Nerva. Referrals don't expire, and patients referred through the form receive 25% off.

Frequently asked questions

Can IBD be misdiagnosed as IBS?

IBD can be mistaken for IBS early on, because both can cause abdominal pain, diarrhea, and urgency. The ACG guideline recommends checking fecal calprotectin or lactoferrin and CRP in suspected IBS with diarrhea, to help rule out IBD.⁷

How do you know if Crohn's disease is in remission?

A Simple Endoscopic Score for Crohn's disease below 4 and a fecal calprotectin below 150 μg/g are the thresholds the 2026 consensus endorsed for defining quiescent disease in research.¹ For ulcerative colitis, it endorsed a Mayo endoscopic subscore of 0 or 1.¹

What symptoms can occur in IBD remission?

Abdominal pain, bloating, and altered bowel habits are the IBS-like symptoms the consensus recognizes in IBD remission.¹ Nausea was rated uncertain, and vomiting and heartburn inappropriate, so those symptoms call for a separate workup.¹

Can you have IBS and ulcerative colitis at the same time?

IBS-type symptoms affect 28.7% of people with ulcerative colitis in remission, compared with 36.6% of those with Crohn's disease, according to a meta-analysis.² The consensus refers to this overlap as IBD with IBS-like symptoms rather than as two separate diagnoses.¹

How do you refer a patient with IBD to a digital gut-brain therapy program?

A referral to Nerva can be made through the clinician form or by recommending the program in a consult. Referrals don't expire, so patients in remission can start when they feel ready.

About this consensus: the joint Rome Foundation and International Organization for the Study of IBD (IOIBD) consensus was developed by a 13-member international panel, with Christopher Ma and Alexander C. Ford as co-first authors and Bruce E. Sands and Lin Chang as senior authors.

References

1. Ma C, Ford AC, Hashash JG, et al. Recommendations for the evaluation and management of inflammatory bowel disease with irritable bowel syndrome-like symptoms: a joint Rome Foundation and International Organization for the Study of IBD (IOIBD) consensus. Gastroenterology. Published online 2026. doi:10.1053/j.gastro.2026.04.008

2. Fairbrass KM, Costantino SJ, Gracie DJ, Ford AC. Prevalence of irritable bowel syndrome-type symptoms in patients with inflammatory bowel disease in remission: a systematic review and meta-analysis. Lancet Gastroenterol Hepatol. 2020;5(12):1053-1062. doi:10.1016/S2468-1253(20)30300-9

3. Cox SR, Lindsay JO, Fromentin S, et al. Effects of low FODMAP diet on symptoms, fecal microbiome, and markers of inflammation in patients with quiescent inflammatory bowel disease in a randomized trial. Gastroenterology. 2020;158(1):176-188.e7. doi:10.1053/j.gastro.2019.09.024

4. Keefer L, Taft TH, Kiebles JL, Martinovich Z, Barrett TA, Palsson OS. Gut-directed hypnotherapy significantly augments clinical remission in quiescent ulcerative colitis. Aliment Pharmacol Ther. 2013;38(7):761-771. doi:10.1111/apt.12449

5. Peters SL, Gibson PR, Halmos EP. Efficacy of app-delivered gut-directed hypnotherapy in irritable bowel syndrome patients with co-morbid IBD [DDW 2026 abstract Sa1736]. Gastroenterology. 2026. doi:10.1016/S0016-5085(26)04437-9

6. Anderson EJ, Peters SL, Gibson PR, Halmos EP. Comparison of digitally delivered gut-directed hypnotherapy program with an active control for irritable bowel syndrome. Am J Gastroenterol. 2025;120(2):440-448. doi:10.14309/ajg.0000000000002921

7. Lacy BE, Pimentel M, Brenner DM, et al. ACG clinical guideline: management of irritable bowel syndrome. Am J Gastroenterol. 2021;116(1):17-44. doi:10.14309/ajg.0000000000001036