Background: Irritable bowel syndrome (IBS) is a common gastrointestinal disorder characterized by recurrent abdominal pain and altered bowel habits. Identifying organic diseases in patients with IBS is crucial, especially when alarming features are present. This study aimed to assess colonoscopic findings in Patients Fulfilling ROME IV Criteria of Irritable Bowel Syndrome with or without recently discovered alarming features. Methods: This cross-sectional study was conducted on sixty consecutive patients with IBS who fulfilled the Rome IV criteria. The patients were divided into two groups: Group A (IBS without alarming features) and Group B (IBS with alarming features). Detailed history, clinical examination, laboratory investigations in the form of complete blood count and full colonoscopy with biopsy were performed. The colonoscopic and histopathological findings were analyzed to determine the presence of organic diseases. Results: Group B exhibited significantly higher occurrences of bleeding per rectum, weight loss, and pallor compared to Group A. Colonoscopic findings revealed a higher prevalence of adenomatous polyps in Group B, whereas Group A showed higher rates of normal findings and lymphocytic colitis. Age above 50 may have association with organic colonic diseases. Conclusion: Absence of alarming features cannot exclude organic colonic diseases in IBS patients, influencing clinical management.