What are the Rome criteria for diagnosing functional gastrointestinal disorders, such as Irritable Bowel Syndrome (IBS)?

Rome Criteria for Diagnosing Functional Gastrointestinal Disorders

The Rome criteria are standardized diagnostic criteria used to identify functional gastrointestinal disorders (FGIDs), with the most current version being Rome IV, which defines irritable bowel syndrome (IBS) as recurrent abdominal pain occurring at least 1 day per week in the last 3 months, associated with two or more of: pain related to defecation, change in stool frequency, or change in stool form. 1

Evolution of Rome Criteria

Manning Criteria (Precursor to Rome)

• First established criteria for IBS diagnosis, including six key symptoms 1:
  1. Abdominal pain relieved by defecation
  2. Looser stools with onset of pain
  3. More frequent stools with onset of pain
  4. Abdominal distension
  5. Passage of mucus in stools
  6. Sensation of incomplete evacuation

Rome I Criteria (Early 1990s)

• Required at least three months of recurrent symptoms 1:
  1. Abdominal pain/discomfort relieved with defecation, or associated with change in stool frequency/consistency
  2. Two or more of the following on at least 25% of occasions:
     • Altered stool frequency
     • Altered stool form
     • Altered stool passage
     • Passage of mucus
     • Bloating or distension 1

Rome II Criteria (1999)

• Required 12 weeks (not necessarily consecutive) in the past 12 months of abdominal discomfort/pain with two of three features 1:

  1. Relieved by defecation
  2. Associated with change in frequency of stool
  3. Associated with change in consistency of stool

• The supportive symptoms from Rome I were no longer mandatory for diagnosis 1

Rome III Criteria (2006)

• Similar to Rome II but with modified timeframe:
  • Symptoms must have originated 6 months prior to diagnosis
  • Been active for the past 3 months 1

Rome IV Criteria (2016)

• Current standard requiring recurrent abdominal pain at least 1 day/week in the last 3 months, with symptom onset at least 6 months before diagnosis, associated with two or more of 1:
  1. Related to defecation
  2. Associated with change in stool frequency
  3. Associated with change in stool form/appearance 1

Clinical Impact of Rome Criteria Evolution

• Rome IV criteria are more restrictive than Rome III, resulting in lower prevalence estimates (4.1% vs 10.1% globally) 1
• Up to 50% of patients who met Rome III criteria may not meet Rome IV criteria, being reclassified as having other functional bowel disorders 1
• Rome IV criteria identify patients with more severe symptoms and higher psychological comorbidity 1

Diagnostic Approach Using Rome Criteria

Initial Assessment

• Evaluate for "red flags" that warrant further investigation 1:
  • Weight loss
  • Rectal bleeding
  • Anemia
  • Nocturnal symptoms
  • Family history of colorectal cancer or IBD 2

Supportive Clinical Features

• Female predominance (approximately 2:1 female to male ratio) 1
• Age <45 years with symptoms >2 years 1
• History of frequent healthcare visits for non-gastrointestinal complaints 1
• Associated non-gastrointestinal symptoms (lethargy, poor sleep, fibromyalgia, backache, urinary frequency) 1

Diagnostic Testing

• Limited testing is recommended for typical presentations 1:
  • Stool Hemoccult and complete blood count are recommended as baseline 1
  • Consider sigmoidoscopy if colonic symptoms are present 1
  • Additional testing (thyroid function, celiac antibodies, stool studies) based on clinical presentation 1
  • Colonoscopy for patients >45 years or with family history of colorectal cancer 1

Subtyping of IBS Based on Rome Criteria

• IBS is further classified into subtypes based on predominant stool pattern 1, 3:
  • IBS with constipation (IBS-C)
  • IBS with diarrhea (IBS-D)
  • Mixed IBS (IBS-M) - previously called alternating IBS (IBS-A)
  • Unsubtyped IBS 3

Clinical Pitfalls and Caveats

• Rome criteria were initially developed for research purposes, not clinical practice, though they have evolved to be more clinically applicable 2
• Absence of abdominal pain makes IBS diagnosis untenable 2
• Symptoms often fluctuate over time, and subtype classification may change 1
• Functional disorders frequently overlap with each other, complicating diagnosis 4
• In IBD patients, functional symptoms may coexist, with prevalence estimated at 39% 1
• Once a functional diagnosis is established, the incidence of new non-functional diagnoses is extremely low 1

Practical Application

• Rome criteria should guide diagnosis but not become a "straitjacket" preventing clinical judgment 1
• Many patients with abdominal pain and disturbed bowel habit may not exactly fit these criteria yet have a similar clinical course 1
• Working diagnosis can usually be safely made in primary care with typical symptoms, normal physical examination, and absence of red flags 1
• Diagnosis should be confirmed through observation over time in primary care 1