A comparative review of inflammatory bowel disease guidelines: JSGE, ECCO, AGA, and ACG

Abstract

Inflammatory bowel disease (IBD), encompassing ulcerative colitis (UC) and Crohn’s disease (CD), is managed according to clinical practice guidelines that integrate evidence appraisal with regional healthcare contexts. This narrative, comparative review examined selected guideline documents from the Japanese Society of Gastroenterology (JSGE), European Crohn’s and Colitis Organisation (ECCO), American Gastroenterological Association (AGA), and American College of Gastroenterology (ACG) using the JSGE guidelines as the organizing framework to highlight similarities and differences in recommendation direction and contextual nuance. The analysis focused on the guideline architecture and selected domains of monitoring and medical therapy, with particular attention to how document structure, scope, publication timing, and update strategies shape the interpretation of similarities and differences in recommendation direction. Across the guideline systems, general agreement in overall direction was observed regarding the shift from symptom-based assessment alone towards objective monitoring, the sustained role of 5-aminosalicylic acid (5-ASA) in the treatment of UC, the expanding integration of advanced therapies, and the adoption of risk-based surveillance principles for IBD-associated colorectal neoplasia. The most notable divergence concerned the use of 5-ASA in CD treatment: the JSGE guidelines retained a more pragmatic role for this therapy, whereas the recent ECCO, AGA, and ACG guidelines generally limited routine use. Treatment withdrawal and de-escalation emerged as particularly heterogeneous domains, reflecting the uneven treatment of drug-specific recommendations. The JSGE guidelines were notable for their distinctive single-volume integration of diagnostic criteria, treatment strategy, and follow-up, as well as their explicit inclusion of Japan-specific considerations, such as nucleoside diphosphate-linked moiety X-type motif 15 genotyping, cytapheresis, and oral tacrolimus. These findings suggest that apparent differences among IBD guidelines should be understood not only as differences in clinical judgment, but also as products of guideline architecture, update timing, and intended scope.