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 consensus-based diagnostic tools that have evolved through multiple iterations (Rome I through Rome IV), with Rome IV being the current standard requiring recurrent abdominal pain 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 the Rome Criteria

The Rome criteria have undergone significant revisions since their inception:

Rome I Criteria

• Required at least 3 months of recurrent symptoms including abdominal pain or discomfort relieved with defecation, or associated with change in stool frequency or consistency 2
• Required two or more supportive features present on at least 25% of occasions: altered stool frequency, altered stool form, altered stool passage, passage of mucus, or bloating/distension 2

Rome II Criteria

• Required 12 weeks or more in the last 12 months of abdominal discomfort or pain 2
• Pain must have two of three features: relieved by defecation, associated with change in frequency of stool, or associated with change in consistency of stool 2, 1
• The supportive features from Rome I became optional rather than mandatory 2

Rome III Criteria

• Modified the timeframe to require symptoms originating 6 months prior to diagnosis and active for the past 3 months 1
• Maintained the requirement for abdominal pain or discomfort 1

Rome IV Criteria (Current Standard)

• Requires recurrent abdominal pain at least 1 day per week in the last 3 months, with symptom onset at least 6 months before diagnosis 1, 3
• Eliminated "discomfort" from the criteria because it is non-specific and has different meanings across languages 3
• Pain must be associated with two or more of: related to defecation (can worsen or improve), associated with change in stool frequency, or associated with change in stool form/appearance 1, 3

Clinical Impact of Rome IV Changes

The Rome IV criteria are more restrictive than Rome III, resulting in lower prevalence estimates (4.1% vs 10.1% globally) and identifying patients with more severe symptoms and higher psychological comorbidity. 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
• The criteria now focus on pain rather than discomfort, making the diagnosis more specific 3

IBS Subtypes Based on Stool Pattern

Rome criteria classify IBS into subtypes based on predominant stool consistency:

• IBS with constipation (IBS-C): Hard stools >25% of the time and loose stools <25% of the time 2
• IBS with diarrhea (IBS-D): Loose stools >25% of the time and hard stools <25% of the time 2
• IBS-mixed (IBS-M): Both hard and soft stools >25% of the time 2
• IBS-unsubtyped (IBS-U): Neither loose nor hard stools >25% of the time (4% of patients) 2

Manning Criteria (Historical Context)

The Manning criteria preceded the Rome criteria and identified six key symptoms:

1. Abdominal pain relieved by defecation 2, 1
2. Looser stools with onset of pain 2, 1
3. More frequent stools with onset of pain 2, 1
4. Abdominal distension 2
5. Passage of mucus in stools 2
6. Sensation of incomplete evacuation 2

The Manning criteria are more suitable for daily clinical practice, especially in primary care, while Rome criteria are recommended for clinical research and standardization of pharmacological studies. 4

Critical Clinical Application Caveats

Do Not Apply Rome Criteria Rigidly in Practice

The Rome criteria were originally developed for research purposes to allow comparability between drug studies, not as a clinical straitjacket. 2, 1

• Many patients with abdominal pain and disturbed bowel habit do not exactly fit these criteria, yet their clinical course is similar 2, 4
• In primary care, diagnosis should be made based on typical symptoms, normal physical examination, and absence of alarm signs without rigidly applying specific criteria 4

Alarm Features Requiring Investigation

Regardless of meeting Rome criteria, the following features mandate further investigation:

• Age >45-50 years with new-onset symptoms 2
• Weight loss 2, 1
• Rectal bleeding 2, 1
• Nocturnal symptoms 2, 1
• Anemia 2, 1
• Family history of colon cancer 2
• Short history of symptoms 2
• Recent antibiotic use 2

Supportive Clinical Features

The diagnosis is more likely when:

• Female sex (independent predictor) 4, 1
• Age <45 years with symptom duration >2 years 2, 4, 1
• Frequent consultations for non-gastrointestinal symptoms 2, 4
• Patient reports stress aggravates symptoms 2

Practical Diagnostic Approach

For patients in primary care, make the diagnosis based on typical symptoms, normal physical examination, and absence of alarm signs, confirmed by observation over time. 2, 4

• Primary care physicians are well-positioned to make these assessments 4
• Once a functional diagnosis is established, the incidence of new non-functional diagnoses is extremely low 2, 1
• Diagnostic testing should be limited to stool hemoccult and complete blood count as baseline 1
• Sigmoidoscopy should be considered if colonic symptoms are present, with biopsy of any abnormality and all patients with diarrhea to detect microscopic colitis 2

Important Pitfalls to Avoid

• Do not use Rome criteria as a substitute for careful clinical evaluation, especially when alarm symptoms are present 4
• Do not ignore extraintestinal symptoms such as fibromyalgia (coexists in 20-50% of IBS patients), lethargy, poor sleep, back pain, urinary frequency, and dyspareunia 4
• Recognize that symptoms fluctuate over time and subtype classification may change 1
• Functional disorders frequently overlap with each other, complicating diagnosis 1