ArticlePDF AvailableLiterature Review

Rome Criteria and a Diagnostic Approach to Irritable Bowel Syndrome



Functional gastrointestinal disorders (FGIDs) account for at least 40% of all referrals to gastroenterologists. Of the 33 recognized adult FGIDs, irritable bowel syndrome (IBS) is the most prevalent, with a worldwide prevalence estimated at 12%. IBS is an important health care concern as it greatly affects patients' quality of life and imposes a significant economic burden to the health care system. Cardinal symptoms of IBS include abdominal pain and altered bowel habits. The absence of abdominal pain makes the diagnosis of IBS untenable. The diagnosis of IBS can be made by performing a careful review of the patient's symptoms, taking a thoughtful history (e.g., diet, medication, medical, surgical, and psychological history), evaluating the patient for the presence of warning signs (e.g., "red flags" of anemia, hematochezia, unintentional weight loss, or a family history of colorectal cancer or inflammatory bowel disease), performing a guided physical examination, and using the Rome IV criteria. The Rome criteria were developed by a panel of international experts in the field of functional gastrointestinal disorders. Although initially developed to guide researchers, these criteria have undergone several revisions with the intent of making them clinically useful and relevant. This monograph provides a brief overview on the development of the Rome criteria, discusses the utility of the Rome IV criteria, and reviews how the criteria can be applied clinically to diagnose IBS. In addition, a diagnostic strategy for the cost-effective diagnosis of IBS will be reviewed.
Journal of
Clinical Medicine
Rome Criteria and a Diagnostic Approach to Irritable
Bowel Syndrome
Brian E. Lacy and Nihal K. Patel *
Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA;
*Correspondence:; Tel.: +1-603-650-5030
Academic Editor: H. Christian Weber
Received: 14 September 2017; Accepted: 20 October 2017; Published: 26 October 2017
Functional gastrointestinal disorders (FGIDs) account for at least 40% of all referrals
to gastroenterologists. Of the 33 recognized adult FGIDs, irritable bowel syndrome (IBS) is the
most prevalent, with a worldwide prevalence estimated at 12%. IBS is an important health care
concern as it greatly affects patients’ quality of life and imposes a significant economic burden to
the health care system. Cardinal symptoms of IBS include abdominal pain and altered bowel habits.
The absence of abdominal pain makes the diagnosis of IBS untenable. The diagnosis of IBS can
be made by performing a careful review of the patient’s symptoms, taking a thoughtful history
(e.g., diet, medication, medical, surgical, and psychological history), evaluating the patient for the
presence of warning signs (e.g., “red flags” of anemia, hematochezia, unintentional weight loss,
or a family
history of colorectal cancer or inflammatory bowel disease), performing a guided physical
examination, and using the Rome IV criteria. The Rome criteria were developed by a panel of
international experts in the field of functional gastrointestinal disorders. Although initially developed
to guide researchers, these criteria have undergone several revisions with the intent of making them
clinically useful and relevant. This monograph provides a brief overview on the development of
the Rome criteria, discusses the utility of the Rome IV criteria, and reviews how the criteria can be
applied clinically to diagnose IBS. In addition, a diagnostic strategy for the cost-effective diagnosis of
IBS will be reviewed.
Keywords: Rome criteria; irritable bowel syndrome; IBS
1. Case Study
L.J. is a 32 year-old woman referred for a second opinion in gastroenterology. Gastrointestinal
symptoms began 5 years ago after a trip to Mexico. Both she and her husband suffered the acute
onset of nausea, vomiting, abdominal pain and diarrhea after eating at a seaside resort. Several
other dinner guests developed similar symptoms. It was thought that they had food poisoning,
and conservative measures (clear liquids for 2 days, p.r.n. acetaminophen, p.r.n. antiemetics) were
employed. Her husband’s symptoms slowly resolved and his bowel habits returned to normal.
However, since that time, she has been troubled with recurrent episodes of lower abdominal pain
combined with a sense of fecal urgency, tenesmus, and loose, watery, non-bloody stools. She frequently
feels bloated and distended and states that she looks “4 months pregnant”. She saw her internist
shortly after her return from Mexico. Stool studies (ova and parasites, fecal leukocytes, routine stool
cultures) were performed and were normal. Blood work was also normal (complete blood count or
CBC, complete metabolic panel or CMP, and C-reactive protein or CRP were normal). She was told
that this was likely just an after effect of a prior infection and that symptoms would slowly resolve.
However, when her symptoms did not resolve, she saw another internist. Serologic tests (serum TTG
or tissue transglutaminase antibody and serum IgA) to look for celiac disease were negative. Separate
J. Clin. Med. 2017,6, 99; doi:10.3390/jcm6110099
J. Clin. Med. 2017,6, 99 2 of 8
one-month long trials of avoiding dairy, then fructose, and then gluten did not help. Her weight
remained stable and no new symptoms developed. She was told that her symptoms would slowly
resolve and that she should “just learn to eat around it”. Frustrated by her persistent symptoms,
she sought out the advice of a gastroenterologist. A review of symptoms did not elicit any new
meaningful information. Her physical examination was normal. Repeat blood work (CBC, CMP,
and CRP) and a thyroid test (TSH) all returned normal. A colonoscopy was performed and was grossly
normal; random biopsies of the terminal ileum and colon were all normal. The patient was told that
she had “chronic diarrhea” and should use loperamide as necessary. When used routinely, loperamide
improved diarrhea symptoms; however, she still had significant problems with abdominal bloating,
distension and frequent bouts (>1–2 episodes per week) of lower abdominal pain, cramps and severe
urgency of stool. The patient, a biology teacher, has done some research and brought in a list of
questions to be answered. These include: what is my diagnosis? How is the diagnosis made? Will
knowing my diagnosis change my therapy? Are other tests required to make the diagnosis? What
treatment options are available?
2. Introduction
The diagnosis of irritable bowel syndrome can be difficult for a number of reasons: one, symptoms
may change over time, and these fluctuations may make the provider feel as if the disorder is more
complicated than it truly is; two, symptoms of IBS may mimic other disorders (e.g., lactose or fructose
intolerance) and thus may fail to respond to empiric treatment; three, providers may not be aware
of current guidelines or definitions on how to properly make the diagnosis of IBS; four, a precise
biomarker for IBS does not exist—patients may have persistent or recurrent symptoms but providers
cannot order a test to confidently diagnose the condition; and lastly, patients may want testing to
identify the cause of their symptoms, although routine tests generally result as normal, which is
frustrating to the patient, since symptoms persist.
For these and other reasons, a single test with perfect sensitivity and specificity to aid in the
diagnosis of IBS would be ideal. This would not just simplify the diagnosis of IBS but would enable
clinicians to initiate treatment more promptly, reducing the impact of IBS to patients. Unfortunately,
however, a gold standard for the diagnosis of IBS does not yet exist. Thus, clinicians and researchers
have relied on a number of different criteria that have been developed over the years (e.g., Manning,
Kruis, Rome), although none have proved perfect. In the section that follows, the evolution of
diagnostic criteria for IBS will be reviewed.
The Manning criteria were truly the first global IBS diagnostic criteria to be introduced and
have been the most extensively studied. The Manning criteria were proposed in 1978 based on
symptoms thought to occur more frequently in IBS patients compared to those with organic disease [
In contrast to large population questionnaire studies now performed routinely, the sample size of
the questionnaire study used by Manning and colleagues was quite small—only 32 patients with
IBS and 33 patients with an organic disorder. The four main symptoms included looser stools at the
onset of pain, increased frequency of bowel movements after the onset of pain, relief of abdominal
pain after a bowel movement, and abdominal distension. Two additional symptoms were found
to be of increased prevalence in patients with IBS (sensation of incomplete evacuation and fecal
mucus). When 2 of 4 main symptoms were used, a sensitivity of 91% and specificity of 70% was
established; when 2 of 6 symptoms were used, the sensitivity ranged from 84 to 94% and the specificity
was 55%; finally when
3 of 6 symptoms were used, the sensitivity ranged from 63 to 90% and the
specificity ranged from 70 to 93% [
]. The Manning criteria have fallen out of favor, in large part due
to the fact that they do not differentiate IBS with constipation (IBS-C) from IBS with diarrhea (IBS-D),
an important consideration for both drug development and for patient care.
In 1984, Kruis and colleagues reported on a similar set of symptoms used to define IBS: abdominal
pain; bloating; and altered bowel function [
]. In contrast to the Manning criteria, the Kruis criteria
placed a greater emphasis on symptom duration, and in fact suggested a two-year time duration.
J. Clin. Med. 2017,6, 99 3 of 8
More importantly, the Kruis criteria highlighted the need to consider warning signs (“red flags”)
and also to exclude organic disease with a combination of a normal physical examination and basic
laboratory studies (CBC and ESR). Ultimately, however, these criteria were found to be too cumbersome
to use in clinical practice and fell out of favor.
In 1988, a group of international experts met in Rome to discuss functional gastrointestinal
disorders (FGIDs). An overarching goal was to classify the FGIDs using a symptom-based classification
scheme, highlighting the fact that patients report symptoms despite a lack of chemical, radiological
or physiological abnormalities. This culminated in the publication of the Rome criteria in 1992
(later known as Rome I), which increased the medical community’s awareness of FGIDs. Abdominal
bloating, a cardinal symptom of many IBS patients, was not distinguished from abdominal pain.
The criteria for IBS were easily incorporated into research studies but proved unwieldy for clinical
practice. The diagnostic accuracy of the Rome I criteria was evaluated in a study of 339 IBS patients
with a reported sensitivity of 85% and a specificity of 71% [4].
Several years later, the Rome committee met again to revise the initial Rome I criteria, based on
feedback from clinicians, investigators, regulatory agencies and from new information gathered from
the scientific literature. The revised Rome II criteria were published in 1999 [
]. Similar to Rome I,
the Rome II required that symptoms be present for at least 12 weeks out of the preceding 12 months,
although the time did not need to be consecutive. The term “discomfort” was added to the definition,
and a new criterion was added, noting that two of the three abdominal pain-related criteria had to be
required for the diagnosis of IBS to ensure that altered bowel habits were present. Patients were not
categorized into specific subtypes based on bowel habits at that time.
The Rome III criteria were introduced in 2006 with the most significant change being the
classification of IBS by subtypes. Subtypes were based on stool consistency rather than stool
frequency, and included IBS-C (constipation), IBS-D (diarrhea), IBS-M (mixed) and IBS-U (unsubtyped).
Another significant change was that the symptom of bloating as a primary symptom was eliminated
from the definition [
]. This change was based on the view that bloating as a symptom is so widespread
that it is neither sensitive nor specific for IBS alone. A validation study by Ford and colleagues of
patients with IBS symptoms who underwent colonoscopy reported a sensitivity of the Rome III criteria
as 68.8% and specificity of 79.5% [7].
Since the release of the Rome III criteria in 2006, research in the field of IBS has surged. Creative
investigative work in both the basic sciences and clinical sciences identified new etiologies of IBS and
provided a better understanding of the complex pathophysiology that underlies the generation of IBS
symptoms [
]. A variety of new medications were introduced to the market and these focused on
specific IBS subtypes, based, in part, on a better understanding of the underlying pathophysiology.
These advances in knowledge, along with a desire to make the Rome criteria more clinically useful,
resulted in several key changes to the Rome criteria when the fourth iteration was released in 2016 [
The definition and rationale for the changes are outlined below.
Rome IV defined
irritable bowel syndrome (IBS) as a functional bowel disorder in which recurrent
abdominal pain is associated with defecation or a change in bowel habits. Disordered bowel habits are
typically present (i.e., constipation, diarrhea or a mix of constipation and diarrhea), as are symptoms
of abdominal bloating/distension. Symptom onset should occur at least 6 months prior to diagnosis
and symptoms should be present during the last 3 months (Table 1).
The Rome IV criteria (Table 1) differ from the Rome III criteria (Table 2) in several distinct ways.
One, the term “discomfort” was removed from the current definition and diagnostic criteria, because
some languages do not have a word for discomfort or it has different meanings in different languages.
Additionally, based on a study of IBS patients who reported wide variations in their understanding
of these terms, it is unclear whether the distinction between pain and discomfort is qualitative or
quantitative [
]. Two, the frequency of abdominal pain was increased from 3 days per month to
one day per week on average. Although this change seems small, it was based on a large population
study with the goal of increasing the sensitivity and specificity of the criteria [
]. Three, bloating
J. Clin. Med. 2017,6, 99 4 of 8
and distention are now recognized as common symptoms. This highlights the prevalence of these
symptoms in patients with IBS and other FGIDs (i.e., chronic constipation, functional dyspepsia) and
reinforces the earlier findings of Kruis and colleagues [
]. Four, the prior criteria included a somewhat
ambiguous phrase regarding the presence of disordered defecation. This has now been clarified
with the phrase “
. . .
disordered bowel habits are typically present (constipation, diarrhea or a mix
of constipation and diarrhea)”. Lastly, it is now explicitly stated that IBS subtypes are based on
predominant bowel habits on the days with abnormal bowel movements. The Rome committee,
using data from a large population study (Rome Normative GI Symptom Survey; unpublished),
determined that analysis of days without a bowel movement did not increase the specificity of bowel
subtyping, while analyzing only days with abnormal bowel movements increased specificity.
Table 1. IBS Diagnostic Criteria *.
Recurrent abdominal pain on average at least 1 day/week in the last 3 months, associated with two
or more of the following criteria:
1. Related to defecation
2. Associated with a change in the frequency of stool
3. Associated with a change in the form (appearance) of stool
(These criteria should be fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis.)
* Modified from Rome IV [9].
Table 2. Previously used Rome III Diagnostic Criteria for Irritable Bowel Syndrome [6].
Recurrent abdominal pain or discomfort (defined as an uncomfortable sensation not described as
pain) for at least 3 days/month in the last 3 months, associated with two or more of the following:
1. Improvement with defecation
2. Onset associated with a change in the frequency of stool
3. Onset associated with a change in the form (appearance) of stool
These criteria should be fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis.
3. IBS Subtypes
Classifying patients with IBS into specific subtypes based on predominant bowel habits is useful as
it helps focus treatment on the predominant, and often, the most bothersome symptom. IBS is classified
into four subtypes: IBS with predominant constipation (IBS-C), IBS with predominant diarrhea (IBS-D),
with mixed bowel habits (IBS-M) or IBS, unsubtyped. One important change from Rome III, as noted
above, is that the IBS subtype is explicitly based on the patient’s reported predominant bowel habit
on days with abnormal bowel movements, and not on an average of all days, which might include
days with normal bowel habits. Abnormal bowel movements are classified using the Bristol stool form
scale, which is described below. For clinical trials, or when appropriate in clinical settings, subjects
should complete a 14-day bowel diary to most accurately categorize IBS subtypes. Bristol stool types 1
and 2 or types 6 and 7 are considered abnormal [12].
4. Bristol Stool Form Scale
The Bristol stool form scale (BSFS) was developed in the 1990s in the Bristol Royal Infirmary in
England [12]. The authors described seven types of stool, which are noted below:
Type 1: Separate hard lumps, like nuts (hard to pass)
Type 2: Sausage-shaped, but lumpy
Type 3: Like a sausage but with cracks on its surface
Type 4: Like a sausage or snake, smooth and soft
Type 5: Soft blobs with clear cut edges (passed easily)
Type 6: Fluffy pieces with ragged edges, a mushy stool
J. Clin. Med. 2017,6, 99 5 of 8
Type 7: Watery, no solid pieces, entirely liquid
The authors classified stool types 1 and 2 as being associated with constipation, while stool types 6
and 7 were associated with diarrhea (and stool type 5 to some degree). Stool types 3 and 4 were
considered normal stools. The BSFS is a convenient way for patients to describe their bowel habits,
and is routinely used in clinical trials. In addition, at the two extremes (Bristol stool types 1 and 2 or
types 6 and 7), the stool form serves as a rough surrogate marker of colon transit [
]. Patients with
IBS-C have >25% of their bowel movements associated with BSFS 1 or 2, while those with IBS-D
have >25% of their bowel movements associated with BSFS 6 or 7. Those with the mixed subtype of
alternating constipation and diarrhea (IBS-M) have >25% of their bowel movements associated with
BSFS 1 or 2 and >25% of their bowel movements associated with BSFS 6 or 7.
5. Making the Diagnosis of IBS
The illustrated case above exemplifies a typical patient with IBS. It provides us with an opportunity
to apply the current Rome IV criteria in making a diagnosis of IBS. The patient describes symptoms
lasting 5 years, having started after an episode of a suspected infectious food borne gastrointestinal
illness. She reports current symptoms of lower abdominal pain with loose watery stools along with
a sense of urgency, tenesmus, bloating and abdominal distention. She underwent stool and serum
testing which was unremarkable, and reasonable trials of lactose, fructose and gluten avoidance did
not help. Due to persistent symptoms, she underwent a colonoscopy with normal biopsies and was
initiated on treatment to address her diarrhea; however, she was not provided with a diagnosis of IBS,
and continues to have multiple questions and concerns regarding her ongoing symptoms.
Obtaining a detailed history with a few additional questions is warranted to confirm the suspected
diagnosis of IBS. It is important to start by ruling out any warning signs. These include: age over
50 without prior colon cancer screening; the presence of overt GI bleeding; nocturnal passage of
stools; unintentional weight loss; a family history of inflammatory bowel disease or colorectal cancer;
recent changes in bowel habits; and the presence of a palpable abdominal mass or lymphadenopathy.
If these warning signs are absent, further history should be obtained to quantify the frequency of
symptoms and determine whether the patient meets the Rome IV diagnostic criteria. More specifically,
the patient should be asked if her pain is present at least one day a week on average for the last
3 months. In our case, the patient has reported a duration of 5 years, which meets the requirement of
having an onset greater than 6 months prior to diagnosis. The rationale behind the latter two questions
is to ensure that the symptoms are recent, and that there is no organic disease manifesting itself over at
least 6 months. The final component to applying the criteria involves associating the abdominal pain
to bowel habits. A careful history should be obtained to confirm whether abdominal pain is related
to defecation, a change in stool frequency, or a change in the appearance of stool. In order to clarify
the latter characteristic, the Bristol stool chart should be employed as previously described. A benign
physical examination further supports the diagnosis of IBS, although the importance of a physical
examination cannot be underestimated as this does reassure the patient [8,9].
As illustrated in this case, unfortunately the yield of confirmatory testing to rule out an alternate
diagnosis is low. This highlights the rationale outlined in position statements, original articles,
and review articles that extensive testing in patients with symptoms of IBS who meet Rome criteria
is unlikely to uncover a new diagnosis [
]. It is important, however, to obtain a complete blood
count to ensure the absence of an iron deficiency anemia, and a CRP can be requested to lower
the suspicion for inflammatory bowel disease. Alternatively, a fecal calprotectin can be considered,
especially in IBS patients with diarrhea or with diarrhea and constipation, since it can help differentiate
IBS from IBD with good accuracy and may prevent the indiscriminate use of colonoscopy. Celiac
testing should be obtained, ideally in the setting of adequate gluten consumption, since IBS may mimic
this disorder. At this point in the evaluation, if patients meet the diagnostic criteria for IBS, further
testing should be discouraged and education and reassurance provided. Based on a prospective
case-control study including 466 patients, colonoscopy did not change the diagnosis of IBS in 98.1% of
J. Clin. Med. 2017,6, 99 6 of 8
patients [13]. Separate trials of avoiding lactose, fructose and/or gluten as diagnostic maneuvers can
be considered in case symptoms are related to an intolerance to these foods. These trials can be carried
out under the supervision of a dietician to avoid over restriction, ensure nutritional adequacy and
implement strategies that integrate with the patients’ habitual diet. Alternatively, a low-FODMAP diet
(an acronym derived from Fermentable, Oligo-, Di-, Mono-saccharides And Polyols) can be instituted
to eliminate many possible culprit foods all at once [14,15].
6. Case Study: Management
At the initial consultation visit, the first step was to carefully listen to the patient’s story. One of
the most important tools to ensure a satisfactory patient visit is to allow time to let the patient tell
their story. This helps set a strong foundation in building a strong physician–patient relationship.
After the patient provides her history, it may be useful to briefly recapitulate the history, as this lets the
patient know that attention is being paid and also offers a chance to correct any misinterpretation of
the patient’s history. As a part of this process, it is important to review all prior diagnostic studies and
treatments. This is time well-spent, as it will prevent unnecessary repeat testing or therapeutic trials.
It is also important to ask patients whether they have any fears or concerns about their symptoms,
as many patients with IBS symptoms are quite concerned that their symptoms represent a hidden
malignancy or IBD [
]. A brief physical examination should be performed; this too reassures the
patient that complaints are being taken seriously. In this patient, who does not have predominant
symptoms of constipation, a rectal examination is not required, especially since she recently had
a colonoscopy that was normal. However, in patients with constipation symptoms, and certainly
in those without recent colonoscopic evaluation, a careful rectal examination should be performed.
This is useful to help diagnose patients with pelvic floor dyssynergia.
At this point, the patient should be confidently told that she has IBS. She clearly meets Rome
IV criteria. Symptoms have been present for greater than 6 months and have been active for the
last 3 months. She suffers from abdominal pain more than 1 day per week on average, and pain
is temporally related to disordered defecation and to a change in stool appearance and frequency.
There are no warning signs on history or examination. In addition, prior diagnostic testing, including
a colonoscopy with biopsies, and serologic tests to rule out celiac disease, have all been normal.
She should also be told about the possible etiology to her developing IBS, which appears to be post
infectious in nature. It is important that patients walk away from their visit with a confident diagnosis,
as two other key components of a successful patient visit include educating and reassuring the patient
about their condition. However, education and reassurance cannot occur if a diagnosis is not made.
Furthermore, language that communicates diagnostic certainty is essential, since it conveys confidence
in the diagnosis and allows acceptance by the patient, thus preventing further unwarranted testing [
Just as essential, making the diagnosis of IBS with appropriate subtyping, based on an understanding
of the patient’s predominant symptoms, will help guide appropriate therapy.
For this patient, she is told that the diagnosis of IBS is based on a constellation of symptoms,
an absence of warning signs, a normal physical examination, and the results of limited diagnostic tests.
The Rome IV criteria can be explained in terms comfortable to the patient. For this patient, who is quite
savvy, knowing that she meets specific criteria for IBS should be reassuring. In addition, it will provide
her with the appropriate framework to do on-line research on her own. At this point, the patient
should be confidently told that no further testing is required. Extensive testing is unlikely to uncover
an alternative diagnosis and will not reassure the patient. In fact, subjecting each and every patient
with IBS symptoms to a battery of expensive, and sometimes dangerous, tests only undermines their
confidence in the ordering provider. The fourth key component of a successful patient visit involves
working together to improve symptoms. As mentioned, the key symptom (or symptoms) should be
identified and treatment initiated. In this case, the patient appears to have IBS with predominant
diarrhea and therapy can be tailored accordingly. For instance, a low-FODMAP diet could be initiated
with the help of a dietician if she wanted to start with dietary interventions. Alternatively, a gut-directed
J. Clin. Med. 2017,6, 99 7 of 8
antibiotic such as rifaximin would be a very reasonable choice as well [
]. If symptoms of
abdominal pain persist, a low dose tricyclic antidepressant should be initiated. This should improve
visceral pain and may slow colonic transit to some degree [
]. If symptoms persist, subsequent
medication trials could include alosetron, eluxadoline or a bile acid sequestrant [
]. Interventions
such as gut directed hypnotherapy and cognitive behavioral therapy can also be considered in select
patients [
]. The patient should be asked to call the office for a quick follow-up approximately 4 weeks
after initiating therapy. It is also important to schedule a follow-up visit in the office to answer new
questions, continue to reassure and educate the patient, and fine-tune dietary or medical therapy.
7. Conclusions
Establishing the diagnosis of IBS can be challenging since there is no confirmatory test. The development
of criteria since 1978, with its most recent iteration in 2016, have sought to clarify and aid practitioners in
making the diagnosis. A careful history is key to a cost-effective diagnosis of IBS and patients meeting the
Rome IV diagnostic criteria, with a normal physical exam and the absence of any warning signs, should
have only limited testing as outlined above. They should be discouraged from repeated testing and be
provided with reassurance and education instead. The Bristol stool chart should also be used to objectively
describe bowel habits and classify patients into the correct subtype in order to direct treatment according to
the predominant symptom.
Conflicts of Interest: The authors declare no conflict of interest.
Manning, A.P.; Thompson, W.G.; Heaton, K.W.; Morris, A.F. Towards positive diagnosis of the irritable
bowel. Br. Med. J. 1978,2, 653–654. [CrossRef] [PubMed]
Dang, J.; Ardila-Hani, A.; Amichai, M.M.; Chua, K.; Pimentel, M. Systematic review of diagnostic criteria for
IBS demonstrates poor validity and utilization of Rome III. Neurogastroenterol. Motil.
,24, 853. [CrossRef]
Kruis, W.; Thieme, C.; Weinzierl, M.; Schüssler, P.; Holl, J.; Paulus, W. A diagnostic score for the irritable
bowel syndrome. Its value in the exclusion of organic disease. Gastroenterology 1984,87, 1–7. [PubMed]
Tibble, J.A.; Sigthorsson, G.; Foster, R.; Forgacs, I.; Bjarnason, I. Use of surrogate markers of inflammation and
Rome criteria to distinguish organic from nonorganic intestinal disease. Gastroenterology
,123, 450–460.
[CrossRef] [PubMed]
Thompson, W.G.; Longstreth, G.F.; Drossman, D.A.; Heaton, K.W.; Irvine, E.J.; Müller-Lissner, S.A. Functional
bowel disorders and functional abdominal pain. Gut 1999,45, II43–II47. [CrossRef] [PubMed]
Longstreth, G.F.; Thompson, W.G.; Chey, W.D.; Houghton, L.A.; Mearin, F.; Spiller, R.C. Functional bowel
disorders. Gastroenterology 2006,130, 1480–1491. [CrossRef] [PubMed]
Ford, A.C.; Bercik, P.; Morgan, D.G.; Bolino, C.; Pintos-Sanchez, M.I.; Moayyedi, P. Validation of the Rome III
criteria for the diagnosis of irritable bowel syndrome in secondary care. Gastroenterology
,145, 1262–1270.
[CrossRef] [PubMed]
Ford, A.C.; Lacy, B.E.; Talley, N.J. Irritable Bowel Syndrome. N. Engl. J. Med.
,376, 2566–2578. [CrossRef]
Lacy, B.E.; Mearin, F.; Chang, L.; Chey, W.D.; Lembo, A.J.; Simren, M.; Spiller, R. Bowel Disorders. Gastroenterology
2016,150, 1393–1407. [CrossRef] [PubMed]
Spiegel, B.M.; Bolus, R.; Agarwal, N.; Sayuk, G.; Harris, L.A.; Lucak, S.; Esrailian, E.; Chey, W.D.; Lembo, A.;
Karsan, H.; et al. Measuring symptoms in the irritable bowel syndrome: Development of a framework for
clinical trials. Aliment. Pharmacol. Ther. 2010,32, 1275–1291. [CrossRef] [PubMed]
Palsson, O.S.; Whitehead, W.E.; van Tilburg, M.A.; Chang, L.; Chey, W.; Crowell, M.D.; Keefer, L.; Lembo, A.J.;
Parkman, H.P.; Rao, S.S.; et al. Rome IV Diagnostic Questionnaires and Tables for Investigators and Clinicians.
Gastroenterology 2016. [CrossRef] [PubMed]
Lewis, S.J.; Heaton, K.W. Stool form scale as a useful guide to intestinal transit time. Scand. J. Gastroenterol.
1997,32, 920–924. [CrossRef] [PubMed]
J. Clin. Med. 2017,6, 99 8 of 8
Chey, W.D.; Nojkov, B.; Rubenstein, J.H.; Dobhan, R.R.; Greenson, J.K.; Cash, B.D. The yield of colonoscopy
in patients with non-constipated irritable bowel syndrome: Results from a prospective, controlled US trial.
Am. J. Gastroenterol. 2010,105, 859–865. [CrossRef] [PubMed]
Lacy, B.E. The Science, Evidence, and Practice of Dietary Interventions in Irritable Bowel Syndrome.
Clin. Gastroenterol. Hepatol. 2015,13, 1899–1906. [CrossRef] [PubMed]
Shah, S.L.; Lacy, B.E. Dietary Interventions and Irritable Bowel Syndrome: A Review of the Evidence.
Curr. Gastroenterol. Rep. 2016,18, 41. [CrossRef] [PubMed]
Lacy, B.E.; Weiser, K.; Noddin, L.; Robertson, D.J.; Crowell, M.D.; Parratt-Engstrom, C.; Grau, M.V. Irritable
bowel syndrome: Patients’ attitudes, concerns and level of knowledge. Aliment. Pharmacol. Ther.
25, 1329–1341. [CrossRef] [PubMed]
Linedale, E.C.; Chur-Hansen, A.; Mikocka-Walus, A.; Gibson, P.R.; Andrews, J.M. Uncertain diagnostic
language affects further studies, endoscopies, and repeat consultations for patients with functional
gastrointestinal disorders. Clin. Gastroenterol. Hepatol. 2016,14, 1735–1741. [CrossRef] [PubMed]
Lacy, B.E.; Moreau, J.C. Diarrhea-predominant irritable bowel syndrome: Diagnosis, etiology, and new
treatment considerations. J. Am. Assoc. Nurse Pract. 2016,28, 393–404. [CrossRef] [PubMed]
Ford, A.C.; Quigley, E.M.; Lacy, B.E.; Lembo, A.J.; Saito, Y.A.; Schiller, L.R.; Soffer, E.E.; Spiegel, B.M.;
Moayyedi, P. Effect of antidepressants and psychological therapies, including hypnotherapy, in irritable
bowel syndrome: Systematic review and meta-analysis. Am. J. Gastroenterol.
,109, 1350–1365. [CrossRef]
Surdea-Blaga, T.; Baban, A.; Nedelcu, L.; Dumitrascu, D.L. Psychological Interventions for Irritable Bowel
Syndrome. J. Gastrointestin. Liver Dis. 2016,25, 359–366. [PubMed]
2017 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access
article distributed under the terms and conditions of the Creative Commons Attribution
(CC BY) license (
... [2][3][4], with a high disease prevalence and poor quality of life resulting from complex, recurring symptoms, which are socioeconomically burdensome [5,6]. IBS is now diagnosed according to the new Rome IV criteria adopted in 2016 [7]. It is a functional bowel disorder characterized by onset of symptoms in the past six months or earlier and recurrent abdominal pain related to defecation or changes in bowel habits over the past three months [7,8]. ...
... IBS is now diagnosed according to the new Rome IV criteria adopted in 2016 [7]. It is a functional bowel disorder characterized by onset of symptoms in the past six months or earlier and recurrent abdominal pain related to defecation or changes in bowel habits over the past three months [7,8]. Abdominal bloating/distention, feeling of incomplete evacuation, and presence or absence of stool mucus are common symptoms even though these are not included among the diagnostic criteria for IBS [9]. ...
... The participants were men and women over the age of 19 who were diagnosed with IBS according to Rome IV criteria [7]. During the 14-d screening period, participants with Bristol stool form scale (BSFS) ≥ 25% were enrolled as subjects with diarrhea type IBS (IBS-D). ...
Full-text available
Irritable bowel syndrome (IBS) causes intestinal discomfort, gut dysfunction, and poor quality of life. This randomized, double-blind placebo-controlled trial evaluated the efficacy of Lactiplantibacillus (Lp., formerly Lactobacillus) plantarum APsulloc 331261 (GTB1TM) from green tea leaves in participants with diarrhea-predominant irritable bowel syndrome (IBS-D). Twenty-seven participants meeting the Rome IV diagnostic criteria were randomized for GTB1 or placebo ingestion for four weeks and follow-up for two weeks. The efficacy endpoints included adequate global relief of symptoms, assessment of intestinal discomfort symptom severity and frequency, stool frequency, satisfaction, and fecal microbiome abundance. Of all participants, 94.4% and 62.5% reported global relief of symptoms in the GTB1 and placebo groups, respectively, with significant differences (p = 0.037). GTB1 significantly reduced the severity and frequency of abdominal pain, bloating, and feeling of incomplete evacuation. The frequencies of diarrhea were decreased −45.89% and −26.76% in the GTB1 and placebo groups, respectively (p = 0.045). Hence, GTB1 ingestion improved IBS-D patient quality of life. After four weeks treatment, the relative abundance of Lactobacillus was higher in the GTB1 than in the placebo group (p = 0.010). Our results showed that GTB1 enhanced intestinal discomfort symptoms, defecation consistency, quality of life, beneficial microbiota, and overall intestinal health.
... Despite these efforts, no satisfactory subclassification has emerged to date. Most commonly, subclassification is defined by bowel pattern (constipation, diarrhea, mixed) though this has been useful mostly for developing pharmacotherapies targeted at alterations in intestinal motility and/or secretion (3). Moreover, these subgroups have never been fully validated clinically, in part because the classification can change during the course of the illness (4,5) and in part because the definition of these subgroups does not reflect the fact that a distinctive bowel pattern, and likely is not the only important factor defining symptomatology in many IBS patients (6). ...
Full-text available
Objective: Some IBS patients possess detailed memories of the events surrounding their bowel symptom onset ("episodic memories"). In this exploratory study we sought to: (1) examine memory relationship with gastrointestinal (GI) symptom severity, extraintestinal symptoms, and mood; (2) qualitatively explore memory valence and content in IBS patients with or without episodic memories. Methods: Referral IBS patients n = 29; age 47.0± 2.2 years, 79.3% female) enrolled in this cross-sectional, mixed methods research study. Participants completed validated specific memory instruments [Autobiographical Memory Test (AMT), Sentence Completion for Events from the Past Test (SCEPT)] and relevant questionnaires [IBS symptoms 10-cm visual analog scale); SF-36 Health-related quality of life (HRQOL); Perley-Guze and PHQ-15/12: somatization; Beck Depression/Anxiety Inventories). Qualitative analysis examined the content and valence of general memories. Results: 14/29 (48.3%) of IBS subjects endorsed episodic memories of IBS symptom onset, often GI infections/enteritis (35.7%). Recall of the exact year (69%) and month (60%) of symptom onset were common. Episodic memories were associated with greater IBS symptom severity/bother, higher anxiety/depression, and poorer HRQOL. Though AMT and SCEPT memory specificity were not different based on episodic memories, overgeneralization to negatively-valenced cues in the AMT was associated with more severe IBS in those without episodic memory. Qualitative analysis revealed no observable differences in topic focus of IBS patients with and without episodic memories. Conclusions: IBS patients often endorse episodic memories associated with symptom onset, and this recall seems to associate with more severe symptoms. Overgeneralization responses to negative stimuli may lead to worse bowel symptoms in those without episodic memories. IBS memory specificity may associate with qualitative differences in processing psychosocial experiences and might be important to IBS pathophysiology.
... A flowchart of the recruitment process and study design is shown in Fig. 1. Forty-two eligible patients with IBS, aged 18-59 years (mean age 37.8 ± 10.7 years), and had a physician diagnosis of IBS according to the Rome IV diagnostic criteria, and did not have any other gastrointestinal disorders were recruited in this study [17]. Patients with the following criteria were excluded: patients with a history of celiac disease (CD), inflammatory bowel disease (IBD), liver diseases, gastrointestinal surgery, cancer, use of non-steroidal antiinflammatory drugs (NSAIDs), excessive alcohol consumption, systemic use of immunosuppressive agents, and poorly controlled psychiatric disease. ...
Full-text available
Background and objective: Recently, dietary restriction of fermentable carbohydrates (a low-FODMAP diet) in combination with a gluten-free diet (GFD) has been proposed to reduce the symptoms in irritable bowel syndrome (IBS) patients. Different studies reported that IBS has been associated with dysbiosis in the gut microbiota. Additionally , a few studies have reported inflammation in the gastrointestinal (GI) system of adults with IBS. In this study, we aimed to investigate the effects of low FODMAP-gluten free diet (LF-GFD) on clinical symptoms, intestinal microbiota diversity, and fecal calprotectin (FC) level in Iranian patients with IBS. Design: In this clinical trial study, 42 patients with IBS (Rome IV criteria) underwent LF-GFD intervention for 6 weeks. Symptoms were assessed using the IBS symptom severity scoring (IBS-SSS), and fecal samples were collected at baseline and after intervention and analyzed by quantitative 16 S rRNA PCR assay. The diversity of gut microbiota compared before and after 6 weeks of dietary intervention. FC was also analyzed by the ELISA method. Results: Thirty patients (mean age 37.8 ± 10.7 years) completed the 6-week diet. The IBS-SSS was significantly (P = 0.001) reduced after LF-GFD intervention compared to the baseline. Significant microbial differences before and after intervention were noticed in fecal samples. A significant increase was found in Bacteroidetes, and the Firmicutes to Bacteroidetes (F/B) ratio was significantly (P = 0.001) decreased after the dietary intervention. The value of FC was significantly decreased after 6 weeks of dietary intervention (P = 0.001). Conclusions: Our study suggests that patients with IBS under an LF-GFD had a significant improvement in IBS symptoms severity, with reduced FC level following normalization of their gut microbiota composition. Further rigorous trials are needed to establish a long-term efficacy and safety of this dietary intervention for personalized nutrition in IBS.
... 23,24 Irritable bowel syndrome (IBS) diagnosis was made according to Rome III criteria. 25 Stool samples of all research participants (patients and controls) were collected in dedicated 30 mL sterile stool screw cap polypropylene containers for storage at −20°C, with spoon collectors (Euro Med), then brought to the lab in a maximum 2-hour interval after collection. For overall gut microbiota DB assessment, progressive dilutions in saline water from 10 −1 to 10 −5 were obtained, and 0.1 mL of the stool samples was placed on different culture media for aerobe, anaerobe, and microaerophilic spp. ...
Full-text available
Background: Gallstone disease (GSD) is more commonly presented in aged people. Purpose: The purpose of the study was to explore the insights of metabolic performance of bacterial species from gut microbiota as well as the clinical background in middle-aged and elderly patients with GSD. Patients and methods: This is an observational study concerning 120 research participants. Of those, 90 patients with symptomatic GSD addressed for cholecystectomy, average age 59.83 ± 15.32 years: 45 with cholesterol rich gallstones (CGSs), 45 with pigment gallstones (PGSs) and 30 healthy controls joined this observational study. Clinical examination, lab work-ups, upper and lower digestive video-endoscopies, abdominal ultrasound/CT and gallbladder motility assessment by Dodd's method were performed. Overall stool dysbiosis (DB) was assessed as 1 = minor, 2 = mild, 3 = severe, species being identified by matrix-assisted laser desorption ionization method. Stool samples from dysbiotic patients were analyzed by a next generation sequencing method with operational taxonomic unit identification. Results: Patients with GSD presented with a significant high range of overall gut DB (p < 0.0001) when compared with controls. Those with CGSs compared with those having PGSs displayed significant clinical differences related to elderly age, lifestyle and diet particularities, obesity, dyslipidemia, nonalcoholic fatty liver disease, hypertension, type 2 diabetes mellitus or impaired glucose tolerance, as well as motility disturbances of gallbladder with a decrease of the ejection fraction. Significant increase of overall DB range and alterations of several functional bacterial species with a decrease of butyrate, lactate, acetate/propionate and methane producers, mucin degrading bacteria, biodiversity index of microbiota, as well as an increase of lipopolysaccharide positive bacteria were significantly present in patients with CGSs. Conclusion: Middle-aged and elderly patients with GSD and a clinical background characterized by particular lifestyle, metabolic and gallbladder motility issues displayed significant modifications of biodiversity, overall gut DB and alterations of several functional bacterial species, with a decrease of their metabolic performance.
... The 2006 Rome III criteria define IBS as three months of recurrent abdominal pain that occurs at least one day per week and is associated with at least two of the following: defecation, change in frequency of stool, and change in form of stool. Additionally, symptom onset should be six months prior to diagnosis [3]. In the United States, about 10% of the population fulfills the Rome III criteria for IBS, making it a relatively common condition [4]. ...
Background Irritable bowel syndrome (IBS) is a "brain-gut disorder" that lacks laboratory, radiologic, or physical exam findings. Colonoscopies are not routinely performed unless "red flag" symptoms, such as bleeding or abnormal weight loss, are present. Socio-demographics have been implicated as sources of potential disparities in appropriate care. Aims We hypothesize that the incidence of red flag symptoms and pursuant colonoscopies differ by socio-demographic status in patients with IBS. Methods Patients diagnosed with IBS were extracted from the National Inpatient Sample 2001-2013 using the International Classification of Diseases, Ninth Revision (ICD-9) codes. Gastrointestinal bleed, blood in stool, weight loss, and anemia were pooled into red flag symptoms. Colonoscopies during the admission were identified using ICD-9 procedural codes. Chi-square analysis and binomial logistic regression were used to evaluate potential disparities with α<0.01. Results Patients with Medicaid or Medicare or those without insurance had higher odds of presenting with red flag symptoms compared to those with private insurance. Medicaid patients and uninsured patients had higher odds of undergoing colonoscopies. All patients that were not Caucasian had higher odds of presenting with red flags and subsequently undergoing colonoscopies. Older patients had higher odds of presenting with concerning red flag symptoms but lower odds of undergoing colonoscopies. Conclusions The incidence of red flag symptoms and performance of colonoscopies differed by socio-demographics in patients with IBS. Patients with non-private or those without insurance were more likely to have red flags and undergo a colonoscopy. Age and race also increased rates of red flag symptoms while having a mixed effect on pursuant colonoscopies. This may represent discrepancies in healthcare utilization in a vulnerable population.
... Our analyses have fewer methodological limitations than the previous analyses. The Rome criteria for IBS diagnosis was revised from I to IV over the past two decades [38]., and the randomized controlled trials on IBS performed during this time used different versions of the Rome criteria [39,40]. For example, most randomized controlled trials on alosetron and early trials on ramosetron used Rome I or II [39], but later trials on ramosetron used Rome III [40]. ...
Full-text available
Background Irritable bowel syndrome (IBS) is a chronic gastrointestinal disorder involving gut-brain interactions with limited effective treatment options. Vitamin D deficiency is commonly observed in patients with IBS, but whether vitamin D supplementation ameliorates IBS is controversial in randomized controlled trials. The present systematic review and meta-analysis explored the efficacy of vitamin D supplementation in patients with IBS. Methods We performed a systematic search of potentially relevant publications from PubMed, EMBASE, the Cochrane Central Register of Controlled Studies and the Web of Science up until January 2022. We assessed the weighted mean difference (WMD) and 95% confidence interval (95% CI) of the IBS severity scoring system (IBS-SSS), IBS quality of life (IBS-QoL) and IBS total score (IBS-TS) before and after vitamin D supplementation intervention. Results We included four randomized, placebo-controlled trials involving 335 participants. The differences in IBS-SSS score between participants in the intervention group and the placebo group increased after intervention (WMD: -55.55, 95% CI: -70.22 to -40.87, I 2 = 53.7%, after intervention; WMD: -3.17, 95% CI: -18.15 to 11.81, I 2 = 0.0%, before intervention). Participants receiving vitamin D supplementation showed greater improvement in IBS-SSS after intervention than participants receiving placebo treatment (WMD: -84.21, 95% CI: -111.38 to -57.05, I 2 = 73.2%; WMD: -28.29, 95% CI: -49.95 to -6.62, I 2 = 46.6%, respectively). Vitamin D supplementation was also superior to placebo in IBS-QoL improvement (WMD: 14.98, 95% CI: 12.06 to 17.90, I 2 = 0.0%; WMD: 6.55, 95% CI: -2.23 to 15.33, I 2 = 82.7%, respectively). Sensitivity analyses revealed an unstable pooled effect on IBS-TS in participants receiving vitamin D supplementation. Therefore, we did not evaluate the efficacy of vitamin D intervention in IBS-TS. Conclusions This systematic review and meta-analysis suggested that vitamin D supplementation was superior to placebo for IBS treatment.
Introduction Ulcerative colitis (UC) and irritable bowel syndrome (IBS) are distressing chronic diseases associated with abdominal pain and altered bowel habits of unknown aetiology. Results from previous studies indicate that, across both diseases, increased levels of illness-related anxiety and dysfunctional symptom expectations contribute to symptom persistence. Thus, comparing both disorders with regard to common and disease-specific factors in the persistence and modification of gastrointestinal symptoms seems justified. Our primary hypothesis is that persistent gastrointestinal symptoms in UC and IBS can be improved by modifying dysfunctional symptom expectations and illness-related anxiety using expectation management strategies. Methods and analysis To assess the extent to which persistent somatic symptoms are modifiable in adult patients with UC and IBS, we will conduct an observer-blinded, three-arm randomised controlled trial. A total of 117 patients with UC and 117 patients with IBS will be randomised into three groups of equal size: targeted expectation management aiming to reduce illness-related anxiety and dysfunctional symptom expectations in addition to standard care (SC, intervention 1), non-specific supportive treatment in addition to SC (intervention 2) or SC only (control). Both active intervention groups will comprise three individual online consultation sessions and a booster session after 3 months. The primary outcome is baseline to postinterventional change in gastrointestinal symptom severity. Ethics and dissemination The study was approved by the Ethics Committee of the Hamburg Medical Association (2020-10198-BO-ff). The study will shed light onto the efficacy and mechanisms of action of a targeted expectation management intervention for persistent gastrointestinal symptoms in patients with UC and IBS. Furthermore, the detailed analysis of the complex biopsychosocial mechanisms will allow the further advancement of aetiological models and according evidence-based intervention strategies. Trial registration number ISRCTN30800023 .
Objective Functional Gastrointestinal Disorder (FGIDs) are a heterogenous group of disorders, with Irritable Bowel Syndrome (IBS) and Functional Dyspepsia (FD) being the most common disorders worldwide. The purpose of this study was to identify the spectra of FGIDs classified according to the ROME III criteria amongst an adult Pakistani population. It also aimed to correlate the psychosocial alarm symptoms with the prevalence of FGIDs and report the overlap of all FGID. Design This was a community based cross-sectional study. Multi-stage cluster sampling technique was applied, and 1062 households were initially randomly chosen using systematic sampling technique. Only one person from each household was enrolled in the study. After eligibility screening, 860 participating individuals were requested to fill out a structured ROME III interview questionnaire, administered to them by a trained interviewer. Results FGIDs were diagnosed in 468 individuals (54.4%), out of 860 participants. FD was found to be the most prevalent (70.2%), followed by Functional Heartburn (58.9%) and Functional bloating (56.6%). Amongst a total of 468 participants diagnosed with FGIDs, 347 (74.1%) had overlapping disorders. There was also a higher incidence of psychosocial alarm symptoms including higher pain severity (62.6% vs 46.4%) and being victimized at some point in their lives (26.1% vs 6.6%) amongst FGID patients. Conclusion There is a high disease burden of FGIDs in this study population, with approximately half of the population suffering from at least one type of FGID. Overlapping disorders are also common in this part of the world.
Diagnosis of chronic gastrointestinal and pancreatic diseases is challenging because patients generally present with nonspecific symptoms, such as abdominal pain and chronic diarrhea, some of which can last for many years. Although stool assays are more sensitive than serum assays, the former has unique limitations that healthcare providers should be aware of. One algorithm to screen for chronic gastrointestinal and pancreatic issues is to perform stool testing to assess inflammatory, watery (osmotic) and malabsorptive conditions. This chapter will discuss several stool-based screening tests, the major disorders they screen for and clinical performance. Sections on assay and sample limitations are also included. Stool testing can provide valuable diagnostic, prognostic and treatment response information if both the laboratory and clinician understand the benefits and limitations of these assays.
Full-text available
Irritable bowel syndrome (IBS) patients often present psychoform symptoms or psychiatric disorders. Among the psychological factors studied in IBS patients, two seem to influence mostly its severity: catastrophizing and somatization. Somatization is an independent risk factor for IBS. In addition, somatization more than the severity of IBS influences the way the patients perceive their illness, the outcome and the efficacy of treatment. Irritable bowel syndrome patients demonstrate greater catastrophizing scores than controls, and pain catastrophizing is a significant predictor of gastrointestinal symptoms related to pain. In this context we analysed the data regarding the efficacy of two psychological treatments in IBS: cognitive behavioral therapy and hypnosis. Cognitive behavioral therapy is focused on replacing maladaptive coping strategies with more positive cognitions and behaviors. Several studies showed that cognitive behavioral therapy is effective in reducing bowel symptoms in IBS, both post-treatment and short-term follow-up. Gut-directed hypnotherapy has beneficial short-term effects in improving gastrointestinal symptoms of patients with IBS, and the results are maintained after one year in half of the patients. Psychological treatments are a suitable option for selected IBS patients. © 2016, Romanian Society of Gastroenterology. All rights reserved.
Full-text available
Irritable bowel syndrome (IBS) is the best studied of the functional gastrointestinal disorders. It is a highly prevalent disorder characterized by symptoms of abdominal pain, bloating, and disordered bowel habits, which may include constipation, diarrhea, or both. IBS has a significant negative impact on patients, both financially and with regard to their quality-of-life. At present, there is no cure for IBS, and while there are a number of pharmacological therapies available to treat IBS symptoms, they are not uniformly effective. For this reason, many patients and providers are turning to dietary interventions in an attempt to ameliorate IBS symptoms. At first glance, this approach appears reasonable as dietary interventions are generally safe and side effects, including potential adverse reactions with medications, are rare. However, although dietary interventions for IBS are frequently recommended, there is a paucity of data to support their use. The goals of this article are to answer key questions about diets currently recommended for the treatment of IBS, using the best available data from the literature.
Full-text available
Objectives: Irritable bowel syndrome (IBS) is a chronic functional gastrointestinal disorder. Evidence relating to the treatment of this condition with antidepressants and psychological therapies continues to accumulate. Methods: We performed an updated systematic review and meta-analysis of randomized controlled trials (RCTs). MEDLINE, EMBASE, and the Cochrane Controlled Trials Register were searched (up to December 2013). Trials recruiting adults with IBS, which compared antidepressants with placebo, or psychological therapies with control therapy or "usual management," were eligible. Dichotomous symptom data were pooled to obtain a relative risk (RR) of remaining symptomatic after therapy, with a 95% confidence interval (CI). Results: The search strategy identified 3,788 citations. Forty-eight RCTs were eligible for inclusion: thirty-one compared psychological therapies with control therapy or "usual management," sixteen compared antidepressants with placebo, and one compared both psychological therapy and antidepressants with placebo. Ten of the trials of psychological therapies, and four of the RCTs of antidepressants, had been published since our previous meta-analysis. The RR of IBS symptom not improving with antidepressants vs. placebo was 0.67 (95% CI=0.58-0.77), with similar treatment effects for both tricyclic antidepressants and selective serotonin reuptake inhibitors. The RR of symptoms not improving with psychological therapies was 0.68 (95% CI=0.61-0.76). Cognitive behavioral therapy, hypnotherapy, multicomponent psychological therapy, and dynamic psychotherapy were all beneficial. Conclusions: Antidepressants and some psychological therapies are effective treatments for IBS. Despite the considerable number of studies published in the intervening 5 years since we last examined this issue, the overall summary estimates of treatment effect have remained remarkably stable.
IBS affects 7 to 16% of the U.S. population, with subtypes characterized by diarrhea, constipation, or both. Patients may have a response to dietary modification, and an effective doctor–patient relationship may increase symptom control.
Purpose: To provide an overview of irritable bowel syndrome (IBS), specifically the efficacy and tolerability of treatment options for diarrhea-predominant IBS (IBS-D). Data sources: Research articles available via PubMed were reviewed. Conclusions: IBS is a chronic multifactorial disorder that has a negative impact on patient-related quality of life. Genetic factors, psychosociologic factors, alterations in the gut microbiota, and changes in immune, motor, and sensory responses to various stimuli all may be involved in the development of IBS. While pharmacologic therapies for IBS-D have historically been limited (e.g., alosetron), newer therapies (eluxadoline and rifaximin), both approved in the United States in 2015, may be considered for appropriate patients for the management of IBS-D. Implications for practice: Nurse practitioners play an important role in the diagnosis, care, and management of patients with IBS-D. The goals of therapy should be to reach a correct diagnosis before initiating therapy, provide reassurance to the patient, educate the patient on potential treatment options, improve IBS-D symptoms, minimize risk of harm with treatment, and maximize patient-related quality of life. The authors present a treatment algorithm to guide nurse practitioners on the management of patients with IBS-D.
Background & aims: Although guidelines state that functional gastrointestinal disorders (FGID) can be diagnosed with minimal investigation, consultations and investigations still have high costs. We investigated whether these are due to specific behaviors of specialist clinicians, examining differences in clinician approaches to organic gastrointestinal diseases vs FGIDs. Methods: We performed a retrospective review of 207 outpatient department letters written from the gastroenterology unit at a tertiary hospital following patient consultations from 2008 through 2011. We collected data from diagnostic letters and case notes relating to patients with organic (n=108) or functional GI disorders (n=119). We analyzed the content of each letter using content analysis, and reviewed case files to determine which investigations were subsequently performed. Our primary outcome was the type of diagnostic language used, and other aspects of the clinical approach. Results: We found gastroenterologists to use 2 distinct types of language: clear vs qualified, consistent with their level of certainty (or lack thereof). For example, "the patient is diagnosed with…." vs "it is possible that this patient might have….''. Qualified diagnostic language was used in a significantly higher proportion of letters about patients with FGID (63%) than organic gastrointestinal diseases (13%) (P<.001). In addition, a higher proportion of patients with FGID underwent endoscopic evaluation than of patients with organic gastrointestinal diseases (79% vs 63%; P<.05). Conclusion: In an analyses of diagnoses of patients with FGIDs vs organic disorders, we found that gastroenterologists use more qualified (uncertain) language in diagnosing patients with FGID. This may contribute to patient discard of diagnoses and lead to additional, unwarranted, endoscopic investigations.
Functional bowel disorders are highly prevalent disorders found worldwide. These disorders have the potential to affect all members of society, regardless of age, gender, race, creed, color or socioeconomic status. Improving our understanding of functional bowel disorders (FBD) is critical as they impose a negative economic impact to the global health care system in addition to reducing quality of life. Research in the basic and clinical sciences during the past decade has produced new information on the epidemiology, etiology, pathophysiology, diagnosis and treatment of FBDs. These important findings created a need to revise the Rome III criteria for FBDs, last published in 2006. This manuscript classifies the FBDs into five distinct categories: irritable bowel syndrome (IBS); functional constipation (FC); functional diarrhea (FDr); functional abdominal bloating/distention (FAB/D); and unspecified FBD (U-FBD). Also included in this article is a new sixth category, opioid induced constipation (OIC) which is distinct from the functional bowel disorders (FBDs). Each disorder will first be defined, followed by sections on epidemiology, rationale for changes from prior criteria, clinical evaluation, physiologic features, psychosocial features and treatment. It is the hope of this committee that this new information will assist both clinicians and researchers in the decade to come.
The Rome IV Diagnostic Questionnaires were developed to screen for functional gastrointestinal disorders, serve as inclusion criteria in clinical trials, and support epidemiologic surveys. Separate questionnaires were developed for adults, children and adolescents, and infants and toddlers. For the adult questionnaire, we first surveyed 1162 adults without gastrointestinal disorders, and recommended the 90th percentile symptom frequency as the threshold for defining what is abnormal. Diagnostic questions were formulated and verified with clinical experts using a recursive process. The diagnostic sensitivity of the questionnaire was tested in 843 patients from 9 gastroenterology clinics, with a focus on clinical diagnoses of irritable bowel syndrome (IBS), functional constipation (FC), and functional dyspepsia (FD). Sensitivity was 62.7% for IBS, 54.7% for FD, and 32.2% for FC. Specificity, assessed in a population sample of 5931 adults, was 97.1% for IBS, 93.3% for FD, and 93.6% for FC. Excess overlap among IBS, FC, and FD was a major contributor to reduced diagnostic sensitivity, and when overlap of IBS with FC was permitted, sensitivity for FC diagnosis increased to 73.2%. All questions were understandable to at least 90% of individuals, and Rome IV diagnoses were reproducible in three-fourths of patients after 1 month. Validation of the pediatric questionnaires is ongoing.
Irritable bowel syndrome (IBS) is a highly prevalent disorder characterized by symptoms of abdominal pain, bloating, constipation and/or diarrhea. The diagnosis can be made using Rome III criteria or published guidelines after taking a thoughtful history, excluding warning signs and performing a careful physical examination. Limited testing (i.e., CBC and CRP) may be useful in appropriate patients. A number of pharmacologic options are available, although many patients fail to respond to pharmacologic therapy. Although several IBS diets are frequently recommended, data supporting their use is limited. This monograph will provide a rationale as to why specific diets might improve IBS symptoms and then evaluate published trials. Copyright © 2015 AGA Institute. Published by Elsevier Inc. All rights reserved.