Irritable bowel syndrome Diagnostic Study of Choice
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]
Overview
As per the Rome IV criteria, the diagnosis of irritable bowel syndrome is made when at least two of clinical features such as change in stool consistency, pain related to defecation and absence of warning signs such as unintentional loss of weight, age ≥50 years, recent change in bowel habit, hematochezia or melena i.e. evidence of overt gastrointestinal bleeding are positive in association with abdominal pain for ≥1 day per week, in the previous 3 months with an onset of ≥6 months. The definition of IBS according to Rome IV, is recurrent abdominal pain associated with a change in frequency and/or form of the stool. It considers IBS as a disorder of gut–brain interaction as opposed to being a functional disorder of the GI tract. The term “abdominal discomfort” mentioned in Rome Ⅲ, has been removed in Rome IV to avoid ambiguity. In addition to this, the frequency of abdominal pain has been changed from at least 3 days a month in the preceding 3 months (Rome III) to at least one day per week in the preceding 3 months (Rome IV). The phrase ‘improvement of abdominal pain with defecation’ in Rome III has been changed to“abdominal pain related to defecation” in the Rome IV criteria, as some IBS patients may report worsening of pain following defecation. Experts state that physicians should limit evaluation to Rome criteria fulfillment, if no alarm symptoms are present.
Diagnostic Criteria
- According to the Rome IV, the diagnosis of IBS is made when patient has pain in the abdomen (on an average, ≥1 day per week, in the previous 3 months) with an onset of ≥6 months before diagnosis. Pain in the abdomen must be associated with at least two of the following: [1]
- Change in stool consistency
- Pain related to defecation
Patient must have none of the following warning signs:
- Unintentional loss of weight
- Age ≥50 years, without previous colon cancer screening
- Recent change in bowel habit
- Hematochezia or melena i.e. evidence of overt gastrointestinal bleeding
- Nocturnal pain in the abdomen or passage of stools
- History of inflammatory bowel disease or colorectal cancer in the family
- Palpable abdominal mass or presence of lymphadenopathy
- Positive fecal occult blood test
- Blood testing showing evidence of iron deficiency anemia
Symptoms concordant with the Rome IV criteria without red flag symptoms exclude organic causes such as lactose intolerance, celiac diseaseand IBD and help make a positive diagnosis of IBS while avoiding unnecessary investigations.
Evolution of the Rome IV criteria:
- In 1978, the first diagnostic criteria (Manning criteria) was published. Manning criteria has a sensitivity of 78% and specificity of 72%.[2][3]
- Kruis criteria published in 1984 has a sensitivity (77%) and specificity (89%). [4]
- The Rome IV criteria were subsequently developed and have undergone three iterations. Rome Ⅰ was revised to Rome Ⅱ, Ⅲ and IV in the years 1999, 2006, 2016 respectively. Rome Ⅰ criteria and determined it had a sensitivity of 71% and specificity of 85%.The Rome Ⅲ criteria have a sensitivity of 75%.[5][6][7][8][9]
- Rome Ⅱ states that a patient must have pain in the abdomen or abdominal discomfort for at least 12 weeks (which may not be consecutive) during the past year. This pain or discomfort must be associated with at least two of the following: change in stool frequency, relief with defecation, change in stool form.[10][11]
- Rome Ⅲ states that a patient must have recurrent pain in the abdomen or discomfort for at least 3 days a month, for the last 3 months associated with two or more of the following features: onset associated with a change in stool frequency, change in stool consistency. or improvement with defecation.[10][12]
- In 2006, criteria based on pharmacological studies were laid down: It required spontaneous bowel movements 3 times per week and one of the following symptoms for at least 12 weeks during the past 12 months: [13][14][15][16][17]
- Straining in one-fourth or more of defecation
- Lumpy or hard stools in one-fourth or more of defecation
- Sensation of incomplete evacuation in one-fourth or more of defecation
- A mean score of 2.0 for daily non menstrual abdominal pain or discomfort
- A mean of 3 complete spontaneous bowel movements and >6 spontaneous bowel movements per week
- In 2009, American College of Gastroenterology (ACG) stated that no criteria based on symptoms could have accuracy for the diagnosis of IBS. It defined IBS as pain in the abdomen or discomfort that was in association with altered bowel habits over at least 3 months.[18][19][20]
- The American Gastroenterological Association has published a set of guidelines for tests which physicians should perform prior to diagnosing irritable bowel syndrome.[21] The following tests are meant to exclude other causes, such as infection and colon cancer.
- History and physical examination
- Diagnostic testing
- CBC
- Chemistry panel
- Sedimentation rate
- Stool for ova & parasites
- Stool for occult blood
- Flexible sigmoidoscopy
- IF > 50, colonoscopy or barium enema and sigmoidoscopy
- For diarrhea predominant:
- For constipation predominant:
- Fiber trial
- For pain predominant:
- Plain film of abdomen
- Difference between Rome III and IV criteria: [22][23][24][25][12][26]
- The definition of IBS is recurrent abdominal pain associated with a change in frequency and/or form of the stool.
- Rome IV defines IBS as a disorder of gut-brain interaction as opposed to being a functional disorder of the GI tract.
- The Rome III criteria mentioned the term “abdominal discomfort”, which has been removed in Rome IV to avoid ambiguity.
- The frequency of abdominal pain has been changed from at least 3 days a month in the preceding 3 months (Rome III) to at least one day per week in the preceding 3 months (Rome IV).
- The phrase ‘improvement of abdominal pain with defecation’ in Rome III has been changed to“abdominal pain related to defecation” as some IBS patients may report worsening of pain following defecation.[27]
- Rome IV states that some symptoms must be present for at least 6 months and that patients must meet the criteria for at least 3 months before IBS is diagnosed.
- Experts state that physicians should limit evaluation to Rome criteria fulfillment if no alarm symptoms are present.[28]
The comparison table for diagnostic studies of choice for IBS[5][29]
| C | Sensitivity | Specificity |
|---|---|---|
| Rome Ⅲ | 75% ✔ | 85% |
| Rome IV | 62% | 97% ✔ |
✔= The best test based on the feature
Sequence of Diagnostic Studies
- The patient presents with symptoms such as recurrent pain in the abdomen (On an average, ≥1 day per week, in the previous 3 months) with an onset of ≥6 months before diagnosis accompanied by at least two of the following: change in stool frequency, change in stool appearance or Pain related to defecation. In addition, the patient must have none of the following warning signs as the first step of diagnosis.
- Physicians should limit evaluation to Rome IV criteria fulfillment if no alarm symptoms are present.
- All the criteria described for IBS are listed below in reverse chronological order:
| Diagnostic criteria | Symptoms, signs and labs |
|---|---|
| 2016: Rome IV[30] | To establish the diagnosis, the patient must have recurrent pain in the abdomen (On an average, ≥1 day per week, in the previous 3 months) with an onset of ≥6 months before diagnosis-
Pain in the abdomen must be associated with at least two of the following:
Patient must have none of the following warning signs:
|
| 2006: Rome Ⅲ[10][27] | Recurrent pain in the abdomen or discomfort at least three days a month, for the last three months associated with two or more of the following (should be present for at least twenty five percent of the time)
|
| 1999: Rome Ⅱ [10][11] | Pain in the abdomen or abdominal discomfort that has two of the following three features for twelve weeks(which may not be consecutive) in the last one year:
|
| 1990: Rome Ⅰ | Abdominal discomfort or pain relieved with defecation or associated with change in frequency or consistency of stool in addition to two or more of the following (on at least twenty five percent of occasions/days for three months):
1. Altered stool form 2. Altered stool frequency 3. Altered stool passage 5. Abdominal bloating or distension |
| 1984: Kruis [4] | Symptoms of IBS must be present for more than two years. These symptoms include the following:
1. Pain in the abdomen, flatulence 2. Alternating constipation and diarrhea Signs that exclude IBS are determined by the physician. They are as follows: 1. Abnormal physical findings and/or history suggestive of any other diagnosis 2. ESR more than 20mm/2h 3. Anemia (hemoglobin < 12 mg/dl for women or < 14 mg/dl for men) 4. Leukocytosis > 10000/cc 5. Bleeding per rectum found on physical exam |
| 1978: Manning [2] | A threshold of at least three positive symptoms needs to be present to diagnose IBS with no duration of symptoms described under this classification.
1) Loose stools with onset of pain 2) Increased frequency of stools with onset of pain 4) Visible distension of abdomen reported by the patient 5) Pain in the abdomen relieved by defecation 6) Sensation of incomplete evacuation |
References
- ↑ Iwańczak B, Iwańczak F (2017). "[Functional gastrointestinal disorders in children and adolescents. The Rome IV criteria]". Pol. Merkur. Lekarski (in Polish). 43 (254): 75–82. PMID 28875974.
- ↑ 2.0 2.1 Manning AP, Thompson WG, Heaton KW, Morris AF (1978). "Towards positive diagnosis of the irritable bowel". Br Med J. 2 (6138): 653–4. PMC 1607467. PMID 698649.
- ↑ Talley NJ, Phillips SF, Melton LJ, Mulvihill C, Wiltgen C, Zinsmeister AR (1990). "Diagnostic value of the Manning criteria in irritable bowel syndrome". Gut. 31 (1): 77–81. PMC 1378344. PMID 2318433.
- ↑ 4.0 4.1 Kruis W, Thieme C, Weinzierl M, Schüssler P, Holl J, Paulus W (1984). "A diagnostic score for the irritable bowel syndrome. Its value in the exclusion of organic disease". Gastroenterology. 87 (1): 1–7. PMID 6724251.
- ↑ 5.0 5.1 Whitehead WE, Drossman DA (2010). "Validation of symptom-based diagnostic criteria for irritable bowel syndrome: a critical review". Am. J. Gastroenterol. 105 (4): 814–20, quiz 813, 821. doi:10.1038/ajg.2010.56. PMC 3856202. PMID 20179688.
- ↑ Lacy BE, Patel NK (2017). "Rome Criteria and a Diagnostic Approach to Irritable Bowel Syndrome". J Clin Med. 6 (11). doi:10.3390/jcm6110099. PMID 29072609.
- ↑ Saps M, van Tilburg MA, Lavigne JV, Miranda A, Benninga MA, Taminiau JA, Di Lorenzo C (2016). "Recommendations for pharmacological clinical trials in children with irritable bowel syndrome: the Rome foundation pediatric subcommittee on clinical trials". Neurogastroenterol. Motil. 28 (11): 1619–1631. doi:10.1111/nmo.12896. PMID 27477090.
- ↑ Thompson WG, Longstreth GF, Drossman DA, Heaton KW, Irvine EJ, Müller-Lissner SA (1999). "Functional bowel disorders and functional abdominal pain". Gut. 45 Suppl 2: II43–7. PMC 1766683. PMID 10457044.
- ↑ Fass R, Longstreth GF, Pimentel M; et al. (2001). "Evidence- and consensus-based practice guidelines for the diagnosis of irritable bowel syndrome". Arch. Intern. Med. 161 (17): 2081–8. PMID 11570936.
- ↑ 10.0 10.1 10.2 10.3 Engsbro AL, Begtrup LM, Kjeldsen J, Larsen PV, de Muckadell OS, Jarbøl DE, Bytzer P (2013). "Patients suspected of irritable bowel syndrome--cross-sectional study exploring the sensitivity of Rome III criteria in primary care". Am. J. Gastroenterol. 108 (6): 972–80. doi:10.1038/ajg.2013.15. PMID 23419383.
- ↑ 11.0 11.1 Saha L (2014). "Irritable bowel syndrome: pathogenesis, diagnosis, treatment, and evidence-based medicine". World J. Gastroenterol. 20 (22): 6759–73. doi:10.3748/wjg.v20.i22.6759. PMC 4051916. PMID 24944467.
- ↑ 12.0 12.1 Dang J, Ardila-Hani A, Amichai MM, Chua K, Pimentel M (2012). "Systematic review of diagnostic criteria for IBS demonstrates poor validity and utilization of Rome III". Neurogastroenterol. Motil. 24 (9): 853–e397. doi:10.1111/j.1365-2982.2012.01943.x. PMID 22632582.
- ↑ Lau M, Ford AC (2015). "Constipation in adults". BMJ Clin Evid. 2015. PMC 4526959. PMID 26245951.
- ↑ Bharucha AE, Pemberton JH, Locke GR (2013). "American Gastroenterological Association technical review on constipation". Gastroenterology. 144 (1): 218–38. doi:10.1053/j.gastro.2012.10.028. PMC 3531555. PMID 23261065.
- ↑ Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC (2006). "Functional bowel disorders". Gastroenterology. 130 (5): 1480–91. doi:10.1053/j.gastro.2005.11.061. PMID 16678561.
- ↑ Lembo AJ, Kurtz CB, Macdougall JE, Lavins BJ, Currie MG, Fitch DA, Jeglinski BI, Johnston JM (2010). "Efficacy of linaclotide for patients with chronic constipation". Gastroenterology. 138 (3): 886–95.e1. doi:10.1053/j.gastro.2009.12.050. PMID 20045700.
- ↑ Johnston JM, Kurtz CB, Macdougall JE, Lavins BJ, Currie MG, Fitch DA, O'Dea C, Baird M, Lembo AJ (2010). "Linaclotide improves abdominal pain and bowel habits in a phase IIb study of patients with irritable bowel syndrome with constipation". Gastroenterology. 139 (6): 1877–1886.e2. doi:10.1053/j.gastro.2010.08.041. PMID 20801122.
- ↑ Brandt LJ, Chey WD, Foxx-Orenstein AE, Schiller LR, Schoenfeld PS, Spiegel BM, Talley NJ, Quigley EM (2009). "An evidence-based position statement on the management of irritable bowel syndrome". Am. J. Gastroenterol. 104 Suppl 1: S1–35. doi:10.1038/ajg.2008.122. PMID 19521341.
- ↑ Sood R, Law GR, Ford AC (2014). "Diagnosis of IBS: symptoms, symptom-based criteria, biomarkers or 'psychomarkers'?". Nat Rev Gastroenterol Hepatol. 11 (11): 683–91. doi:10.1038/nrgastro.2014.127. PMID 25069544.
- ↑ Yawn BP, Lydick E, Locke GR, Wollan PC, Bertram SL, Kurland MJ (2001). "Do published guidelines for evaluation of irritable bowel syndrome reflect practice?". BMC gastroenterology. 1: 11. PMID 11701092.
- ↑ Yawn BP, Lydick E, Locke GR, Wollan PC, Bertram SL, Kurland MJ (2001). "Do published guidelines for evaluation of irritable bowel syndrome reflect practice?". BMC gastroenterology. 1: 11. PMID 11701092.
- ↑ Ghoshal UC (2017). "Pros and Cons While Looking Through an Asian Window on the Rome IV Criteria for Irritable Bowel Syndrome: Pros". J Neurogastroenterol Motil. 23 (3): 334–340. doi:10.5056/jnm17020. PMC 5503282. PMID 28672432.
- ↑ Ghoshal UC (2017). "Chronic constipation in Rome IV era: The Indian perspective". Indian J Gastroenterol. 36 (3): 163–173. doi:10.1007/s12664-017-0757-1. PMID 28643273.
- ↑ Simren M, Palsson OS, Whitehead WE (2017). "Update on Rome IV Criteria for Colorectal Disorders: Implications for Clinical Practice". Curr Gastroenterol Rep. 19 (4): 15. doi:10.1007/s11894-017-0554-0. PMC 5378729. PMID 28374308.
- ↑ Tack J, Drossman DA (2017). "What's new in Rome IV?". Neurogastroenterol. Motil. 29 (9). doi:10.1111/nmo.13053. PMID 28303651.
- ↑ Drossman DA (2016). "Functional Gastrointestinal Disorders: History, Pathophysiology, Clinical Features and Rome IV". Gastroenterology. doi:10.1053/j.gastro.2016.02.032. PMID 27144617.
- ↑ 27.0 27.1 Occhipinti K, Smith JW (2012). "Irritable bowel syndrome: a review and update". Clin Colon Rectal Surg. 25 (1): 46–52. doi:10.1055/s-0032-1301759. PMC 3348735. PMID 23449495.
- ↑ Olden KW (2003). "The challenge of diagnosing irritable bowel syndrome". Rev Gastroenterol Disord. 3 Suppl 3: S3–11. PMID 14502111.
- ↑ Ford AC, Bercik P, Morgan DG, Bolino C, Pintos-Sanchez MI, Moayyedi P (2013). "Validation of the Rome III criteria for the diagnosis of irritable bowel syndrome in secondary care". Gastroenterology. 145 (6): 1262–70.e1. doi:10.1053/j.gastro.2013.08.048. PMID 23994201.
- ↑ Heidelbaugh JJ (2017). "These 3 tools can help you streamline management of IBS". J Fam Pract. 66 (6): 346–353. PMID 28574520.