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 IV criteria define 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, with symptom onset at least 6 months before diagnosis. 1

Evolution of the Rome Criteria

• The Rome criteria have evolved through several iterations, beginning with the Manning criteria which established six key symptoms for IBS diagnosis, including abdominal pain relieved by defecation and changes in stool consistency with pain onset. 1

• Rome I criteria required at least three months of recurrent symptoms, including abdominal pain/discomfort relieved with defecation or associated with changes in stool frequency/consistency. 1

• Rome II criteria required 12 weeks of abdominal discomfort/pain with two of three features: relief with defecation, association with change in stool frequency, or association with change in stool consistency. 1

• Rome III criteria modified the timeframe, requiring symptoms to have originated 6 months prior to diagnosis and been active for the past 3 months. 1

• The current Rome IV criteria (established in 2016) are more restrictive than previous versions, resulting in lower prevalence estimates (4.1% vs. 10.1% with Rome III). 1, 2

Current Rome IV Diagnostic Criteria for IBS

• Recurrent abdominal pain, on average, at least 1 day/week in the last 3 months, associated with two or more of the following:

  • Related to defecation
  • Associated with a change in stool frequency
  • Associated with a change in stool form/appearance 1, 2

• Symptoms must have started at least 6 months before diagnosis 1, 2

• The absence of abdominal pain makes the diagnosis of IBS untenable 2

IBS Subtypes Based on Rome IV

• IBS with constipation (IBS-C): >25% of bowel movements with Bristol stool form types 1-2 and <25% with types 6-7 1

• IBS with diarrhea (IBS-D): >25% of bowel movements with Bristol stool form types 6-7 and <25% with types 1-2 1

• Mixed IBS (IBS-M): >25% of bowel movements with Bristol stool form types 1-2 and >25% with types 6-7 1

• Unsubtyped IBS: Patients who meet IBS criteria but whose bowel habits cannot be accurately categorized 1

Diagnostic Approach Using Rome Criteria

• Initial assessment must evaluate for "red flags" that warrant further investigation:

  • Weight loss
  • Rectal bleeding
  • Anemia
  • Nocturnal symptoms
  • Family history of colorectal cancer or inflammatory bowel disease 1, 2

• Supportive clinical features include:

  • Female predominance
  • Age <45 years with symptoms >2 years
  • History of frequent healthcare visits for non-gastrointestinal complaints 1

• Diagnostic testing should be limited:

  • Stool Hemoccult and complete blood count as baseline tests
  • Sigmoidoscopy if colonic symptoms are present
  • Further testing only if red flags are present 1, 2

Rome IV Criteria for Other Functional Gastrointestinal Disorders

• Functional constipation: Requires two or more of the following criteria for the last 3 months with symptom onset at least 6 months prior:

  • Straining during >25% of defecations
  • Lumpy/hard stools in >25% of defecations
  • Sensation of incomplete evacuation in >25% of defecations
  • Sensation of anorectal obstruction in >25% of defecations
  • Manual maneuvers to facilitate defecation in >25% of defecations
  • Fewer than three spontaneous bowel movements per week 1, 3

• Functional dyspepsia: Requires one or more of the following:

  • Bothersome postprandial fullness
  • Early satiation
  • Epigastric pain
  • Epigastric burning
  • No evidence of structural disease that would explain symptoms 1, 4

Clinical Pitfalls and Caveats

• The Rome criteria were initially developed for research purposes, not clinical practice, though they have evolved to be more clinically applicable. 1

• Symptoms often fluctuate over time, and subtype classification may change, requiring reassessment. 1

• Functional disorders frequently overlap with each other, complicating diagnosis. 1, 4

• 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 compared to previous criteria. 1

• Once a functional diagnosis is established, the incidence of new non-functional diagnoses is extremely low. 1