Irritable bowel syndrome with diarrhea: time to change practice?

Purpose of review Traditional approaches to irritable bowel syndrome with diarrhea (IBS-D) relied on extensive exclusionary testing and empiric symptom management. Recent advances in understanding neuroimmune pathophysiology, refined diagnostic algorithms, emergence of novel biomarkers, and clarification of comparative treatment efficacy through systematic reviews necessitate evaluation of whether accumulated evidence warrants substantive changes to contemporary diagnostic and therapeutic practice in IBS-D management. Recent findings Diagnostic paradigms have shifted toward symptom-based approaches utilizing judicious testing informed by alarm features, with emerging biomarkers including neutrophil-to-albumin ratio, microRNA-148, and bile acid malabsorption markers showing promise. Therapeutically, tricyclic antidepressants demonstrate robust efficacy as neuromodulators, while selective serotonin reuptake inhibitors show limited benefit. Emerging neuroimmune therapies targeting mast cell activation, including histamine receptor antagonists, represent promising avenues. Low FODMAP and Mediterranean diets demonstrate substantial efficacy, while brain–gut behavioral therapies achieve clinically meaningful improvements in refractory populations through accessible delivery modalities. Summary Contemporary evidence supports fundamental practice shifts from exclusionary testing toward targeted investigation of treatable mimics and from empiric management toward mechanism-based multimodal interventions integrating neuromodulators, dietary modifications, and behavioral therapies. Optimal outcomes require individualized treatment selection informed by symptom phenotype and comorbidity profiles, ideally delivered through integrated care models combining gastroenterology, dietetic, and behavioral expertise.