What are the Rome criteria for diagnosing different functional Gastrointestinal (GI) disorders, including Irritable Bowel Syndrome (IBS), functional dyspepsia, and functional constipation?

Rome Criteria for Functional Gastrointestinal Disorders

The Rome IV criteria are the current gold standard for diagnosing functional GI disorders, requiring recurrent symptoms for at least 3 months with onset at least 6 months prior to diagnosis, though less restrictive "clinical criteria" requiring only 8 weeks of symptoms are now recommended for routine practice. 1, 2

Irritable Bowel Syndrome (IBS)

Rome IV Criteria (Current Standard)

IBS requires recurrent abdominal pain at least 1 day per week in the last 3 months, with symptom onset at least 6 months before diagnosis, associated with two or more of the following: 1, 2, 3

• Pain related to defecation (can improve OR worsen with bowel movements) 4
• Change in stool frequency 1, 3
• Change in stool form/appearance 1, 3

Key Changes from Earlier Iterations

Rome IV eliminated "discomfort" as a diagnostic criterion because it is non-specific and has different meanings across languages—only pain is now required. 4

The Manning criteria (historical precursor) included six symptoms: 1, 3

• Abdominal pain relieved by defecation
• Looser stools with onset of pain
• More frequent stools with onset of pain
• Abdominal distension
• Passage of mucus in stools
• Sensation of incomplete evacuation

Rome I criteria required at least 3 months of recurrent symptoms with abdominal pain/discomfort relieved with defecation or associated with change in stool frequency/consistency, plus two or more supportive features (altered stool frequency, altered stool form, altered stool passage, passage of mucus, bloating/distension) on at least 25% of occasions. 1, 3

Rome II criteria required 12 weeks or more in the last 12 months of abdominal discomfort/pain with two of three features: relieved by defecation, associated with change in frequency of stool, or associated with change in consistency of stool. 1, 3

Clinical Impact of Rome IV Restrictions

Rome IV criteria are substantially more restrictive than Rome III, reducing global IBS prevalence from 10.1% to 4.1%, with up to 50% of patients who met Rome III criteria no longer qualifying for IBS diagnosis. 1, 2, 3 These patients are now reclassified as having other functional bowel disorders such as functional diarrhea, functional constipation, or functional abdominal bloating. 1, 3

Rome IV identifies patients with more severe symptoms and higher psychological comorbidity compared to Rome III. 1, 2, 3

Supportive Clinical Features

The diagnosis is more likely if the patient is female, aged <45 years with symptom history >2 years, and has attended frequently in the past with non-gastrointestinal symptoms. 1, 3

Red Flags Requiring Investigation

If symptoms are atypical, history is short, or patient is over 45 years, perform further investigations including: 1

• Sigmoidoscopy or colonoscopy (especially with family history of colon cancer) 1
• Complete blood count to exclude anemia 1
• Thyroid function tests 1
• Antiendomysial antibodies (for celiac disease) 1
• Stool microscopy 1

Warning signs mandating investigation regardless of age include: weight loss, rectal bleeding, nocturnal symptoms, or anemia. 1

Functional Dyspepsia (FD)

Rome IV Criteria

Functional dyspepsia requires one or more bothersome symptoms (epigastric pain, epigastric burning, postprandial fullness, or early satiation) present for the last 3 months, with symptom onset at least 6 months before diagnosis, and no structural disease on upper endoscopy to explain symptoms. 1, 2

"Bothersome" specifically means symptoms severe enough to impact usual activities. 1, 2

Clinical Criteria for Routine Practice

The Rome Foundation acknowledges that requiring symptoms for 3 months with onset 6 months prior is too restrictive for routine care and potentially delays diagnosis and treatment—the new "clinical criteria" require only 8 weeks of cardinal symptoms for practical use. 1, 2

FD Subtypes

Epigastric Pain Syndrome (EPS) requires one or both of the following at least 1 day per week: 1, 2

• Bothersome epigastric pain (severe enough to impact usual activities)
• Bothersome epigastric burning (severe enough to impact usual activities)

Pain may be induced by meals, relieved by meals, or occur while fasting. 1

Postprandial Distress Syndrome (PDS) requires one or both of the following at least 3 days per week: 1, 2

• Bothersome postprandial fullness (severe enough to impact usual activities)
• Bothersome early satiation (severe enough to prevent finishing a regular-sized meal)

Critical Diagnostic Requirements

Upper endoscopy is required by definition to exclude structural disease in functional dyspepsia. 1, 2 Approximately 80% of patients with dyspepsia symptoms will have functional dyspepsia after endoscopy excludes structural disease. 2

Important Exclusions

Heartburn is not a dyspeptic symptom, but may often coexist. 1

Symptoms relieved by evacuation of feces or gas should generally not be considered as part of dyspepsia. 1

Persistent vomiting likely suggests another disorder. 1

Functional Constipation

Rome IV categorizes disorders of chronic constipation into four subtypes: functional constipation, IBS with constipation (IBS-C), opioid-induced constipation, and functional defecation disorders (including inadequate defecatory propulsion and dyssynergic defecation). 5

Functional bowel disorders (functional diarrhea, functional constipation, IBS-D, IBS-C, and IBS with mixed bowel habits) are considered to be on a continuum rather than as independent entities. 4

Functional Abdominal Bloating and Distention

Rome IV has a separate category for abdominal bloating and distention, acknowledging this can be a primary disorder with a global prevalence as high as 3.5% (4.6% in women and 2.4% in men). 1

When Rome IV diagnostic criteria for functional abdominal bloating and distention are met, the patient should not fulfill criteria for IBS, functional constipation, functional diarrhea, or functional dyspepsia. 1

Bloating and distention are much more prevalent (>50%) when associated with other disorders of gut-brain interaction. 1

Critical Clinical Pitfalls

The Rome criteria were initially developed for research purposes with pharmaceutical industry support to allow greater comparability between drug studies—they should not become a straitjacket to prevent clinical judgment. 1, 3

Many patients with abdominal pain and disturbed bowel habit do not exactly fit these criteria, yet their clinical course is similar. 1

Once a functional diagnosis is established using appropriate criteria and limited investigation, the incidence of new non-functional diagnoses is extremely low. 1, 2

Functional disorders frequently overlap with each other, complicating diagnosis, and symptoms often fluctuate over time with subtype classification potentially changing. 3

Terminology Update

Functional gastrointestinal disorders (FGIDs) are now called disorders of gut-brain interaction (DGBI) in Rome IV, reflecting the multicultural rather than Western-culture focus. 4