The study, published in Frontiers in Gastroenterology, was designed to answer a question that has lingered in gastroenterology for decades: does having IBS-like symptoms on top of IBD actually change the course of the disease, or does it simply make patients feel miserable while their IBD smolders quietly? Previous estimates suggested that roughly a third of IBD patients in remission experience IBS-type symptoms, a rate far above the roughly six percent prevalence of IBS in the general population. Yet those estimates varied wildly depending on how remission was defined, and earlier longitudinal studies relied on fecal calprotectin thresholds that many experts consider too permissive to exclude ongoing intestinal inflammation.

To tighten the methodology, the Boston team recruited adults with established IBD at the time of a scheduled colonoscopy between 2020 and 2022. Quiescence was defined endoscopically, using a Mayo score of zero or one for ulcerative colitis and the absence of ulcerations for Crohn’s disease, and the great majority of participants, 84.2 percent, were also in histological remission. At the same visit, patients completed the IBS Symptom Severity Scale, a validated questionnaire that allowed the investigators to sort them into three groups: no IBS-like symptoms in 53 patients, mild symptoms in 43, and moderate to severe symptoms in 18. The researchers then manually extracted clinical data from the electronic medical record through September 2025, yielding a median follow-up of 3.5 years that was comparable across all three groups.

The primary outcome was total IBD-related healthcare utilization, a deliberately broad measure that captured clinic visits, endoscopic and imaging evaluations, emergency department visits, hospitalizations, surgeries, and even complications of IBD medications. The results showed a clear gradient. Patients with no IBS-like symptoms accumulated a median of 8 utilization events, those with mild symptoms 12, and those with moderate-severe symptoms 7, a difference that reached statistical significance. Expressed differently, patients with mild symptoms logged 391 events over 132.3 patient-years and those with moderate-severe symptoms 223 events over 62.9 patient-years, compared with 447 events over 183.7 patient-years among symptom-free patients. A negative binomial regression adjusting for IBD type and biologic therapy confirmed higher adjusted incidence rate ratios of 1.214 for mild and 1.393 for moderate-severe symptoms.

Perhaps the most clinically provocative finding emerged from the time-to-event analysis of unscheduled or acute care, defined as imaging, emergency department visits, hospitalizations, and surgeries, excluding routine monitoring visits and endoscopies. After multivariable adjustment, mild IBS-like symptoms carried a hazard ratio of 3.6 for unscheduled acute utilization, and moderate-severe symptoms a hazard ratio of 6.2, relative to patients without such symptoms. The Kaplan-Meier curves revealed that most of this excess risk accumulated within the first year after the index colonoscopy before plateauing. The authors caution that the absolute number of acute events was small, making these hazard ratios exploratory, but the direction and magnitude of the effect are difficult to ignore.

Dissecting where the extra utilization came from proved illuminating. The excess was driven mainly by imaging studies such as CT and MRI enterography, which accounted for 6 to 8 percent of events in the symptomatic groups versus only 1 percent in the asymptomatic group. By contrast, endoscopies were proportionally more common among patients without IBS-like symptoms, consistent with proactive surveillance rather than symptom-driven investigation. Hospitalizations and emergency department visits were rare across the board. This pattern suggests that when patients with quiescent IBD but troublesome symptoms present to their physicians, clinicians often reach for cross-sectional imaging to hunt for inflammation that endoscopy has already largely excluded, an expensive and radiation-bearing reflex that may frequently be unnecessary.

Equally important was what the study did not find. Among the 59 patients on biologic therapy at baseline, treatment failure, defined as drug discontinuation due to primary non-response, loss of response, or serious adverse events, did not differ significantly by IBS-like symptom status. Nine percent of patients without symptoms discontinued their biologic, compared with 27 percent of those with moderate-severe symptoms, a numerical gap that failed to reach statistical significance. This aligns with two prior studies from a United Kingdom cohort led by Gracie and Fairbrass, which similarly found that IBS-type symptoms predicted greater healthcare use and worse quality of life but not longitudinal disease activity, steroid need, therapy escalation, hospitalization, or intestinal resection.

The psychological dimension of the findings deserves attention. Using the PROMIS measurement system, where 50 represents the population average, the study recorded progressively higher anxiety and depression scores across the symptom groups. Patients with no IBS-like symptoms averaged 47.2 on the anxiety scale, while those with moderate-severe symptoms averaged 58.9, and depression scores followed the same pattern. The authors acknowledge that this psychological burden, together with the possibility of surveillance bias, may partly explain the elevated healthcare-seeking behavior. The underlying mechanisms linking IBS-like symptoms to IBD remain elusive, with candidate explanations including post-inflammatory visceral hypersensitivity, microbiome alterations, dysregulated gut-brain interactions, increased intestinal permeability, and low-grade immune activation.

The study is not without limitations, which the authors lay out candidly. Defining IBS within an IBD population remains inherently difficult, and alternative diagnoses such as bile acid diarrhea, small intestinal bacterial overgrowth, or pelvic floor dysfunction could account for some symptoms. Residual microscopic inflammation or proximal small bowel disease could not be fully excluded, fecal calprotectin and C-reactive protein data were available for only a small subset, and the symptom questionnaire was administered only once at baseline even though IBS-type symptoms fluctuate over time. The modest sample size precluded subgroup analyses, the tertiary care population may not represent typical IBD patients, and the COVID-19 pandemic overlapped with early follow-up. Still, the concurrent use of endoscopy and symptom scoring represents a meaningful methodological advance over prior work.

The takeaway for patients and clinicians is both sobering and actionable. IBS-like symptoms in endoscopically quiescent IBD are clinically meaningful, driving substantial healthcare consumption without reflecting inflammatory disease activity, and the authors argue they warrant targeted recognition and treatment within IBD care models. In practical terms, that could mean pairing routine IBD management with therapies proven for functional bowel disorders, including gut-brain neuromodulators, dietary interventions, and psychological treatments, rather than escalating immunosuppressive drugs in response to symptoms that inflammation scores say should not exist. As biologic therapies push more IBD patients into deep remission, distinguishing the inflamed gut from the irritable one may become one of the specialty’s central challenges, and this study offers a rigorous template for doing exactly that.

Subject of Research: The association of irritable bowel syndrome-like symptoms with healthcare utilization and treatment outcomes in patients with quiescent inflammatory bowel disease

Article Title: Irritable bowel syndrome-like symptoms are associated with increased healthcare utilization in patients with inflammatory bowel disease

Article References: Irritable bowel syndrome-like symptoms are associated with increased healthcare utilization in patients with inflammatory bowel disease. (n.d.). https://doi.org/10.3389/fgstr.2026.1924176

Image Credits: AI Generated

DOI: 10.3389/fgstr.2026.1924176

Keywords: inflammatory bowel disease, irritable bowel syndrome, Crohn's disease, ulcerative colitis, healthcare utilization, endoscopic remission, biologic therapy, treatment failure, gut-brain axis, IBS-SSS, gastroenterology, visceral hypersensitivity