Irritable bowel syndrome Diagnostic Study of Choice: Difference between revisions

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{{Irritable bowel syndrome}}
{{Irritable bowel syndrome}}


{{CMG}}; {{AE}}  
{{CMG}}; {{AE}} {{Cherry}}
==Overview==
==Overview==
===American Gastroenterological Association Guidelines for Diagnosis of IBS===
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 [[Human feces|stool]] consistency, [[pain]] related to [[defecation]] and absence of warning signs such as unintentional [[Weight loss|loss of weight]], age ≥50 years, recent change in [[Intestine|bowel]] habit, [[hematochezia]] or [[melena]] i.e. evidence of overt [[Gastrointestinal tract|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 [[Irritable bowel syndrome|IBS]] according to Rome IV, is recurrent [[abdominal pain]] associated with a change in frequency and/or form of the [[Human feces|stool]]. It considers [[Irritable bowel syndrome|IBS]] as a disorder of [[gut]]–[[brain]] interaction as opposed to being a functional disorder of the [[Gastrointestinal tract|GI tract.]] The term “[[Abdomen|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 [[Irritable bowel syndrome|IBS]] patients may report worsening of [[pain]] following [[defecation]]. Experts state that physicians should limit evaluation to Rome criteria fulfillment, if no alarm [[Symptom|symptoms]] are present.
The [[American Gastroenterological Association]] has published a set of guidelines for tests which physicians should perform prior to diagnosing [[irritable bowel syndrome]].<ref name="YAWN_2001">{{cite journal |author=Yawn BP, Lydick E, Locke GR, Wollan PC, Bertram SL, Kurland MJ |title=Do published guidelines for evaluation of irritable bowel syndrome reflect practice? |journal=BMC gastroenterology|volume=1 |issue= |pages=11 |year=2001 |pmid=11701092 |doi=}}</ref>  The following tests are meant to exclude other causes, such as [[infection]] and [[colon cancer]].


#History and physical examination
==Diagnostic Criteria==
#Diagnostic testing
*According to the Rome  IV, the diagnosis of [[Irritable bowel syndrome|IBS]] is made when patient has [[Abdominal pain|pain in the abdomen]] (on an average, ≥1 day per week, in the previous 3 months) with an onset of ≥6 months before diagnosis. [[Abdominal pain|Pain in the abdomen]] must be associated with at least two of the following: <ref name="pmid28875974">{{cite journal |vauthors=Iwańczak B, Iwańczak F |title=[Functional gastrointestinal disorders in children and adolescents. The Rome IV criteria] |language=Polish |journal=Pol. Merkur. Lekarski |volume=43 |issue=254 |pages=75–82 |year=2017 |pmid=28875974 |doi= |url=}}</ref>
##[[Complete blood count|CBC]]
**Change in [[Human feces|stool]] consistency
##Chemistry panel
**[[Pain]] related to [[defecation]]
##[[Erythrocyte sedimentation rate|Sedimentation rate]]
Patient must have none of the following warning signs:
##Stool for O & P
*Unintentional [[Weight loss|loss of weight]]  
##Stool for occult blood
*Age ≥50 years, without previous [[Colorectal cancer|colon cancer]] [[Screening (medicine)|screening]]
##Flexible [[sigmoidoscopy]]
*Recent change in [[Intestine|bowel]] habit
##IF > 50, [[colonoscopy]] or [[Lower gastrointestinal series|barium enema]] and [[sigmoidoscopy]]  
*[[Hematochezia]] or [[melena]] i.e. evidence of overt [[gastrointestinal bleeding]]
##For diarrhea predominant:
*[[Nocturnal]] [[Abdominal pain|pain in the abdomen]] or passage of [[Human feces|stools]]  
###Small bowel radiograph
*History of [[inflammatory bowel disease]] or [[colorectal cancer]] in the family
###Lactose/dextrose H2 breathing test  
*[[Palpable]] [[abdominal mass]] or presence of [[lymphadenopathy]]
##For [[constipation]] predominant:
*Positive [[Fecal occult blood|fecal occult blood test]]
###Fiber trial
*[[Blood]] testing showing evidence of [[iron deficiency anemia]]
##For pain predominant:
[[Symptom|Symptoms]] concordant with the Rome IV criteria without red flag [[Symptom|symptoms]] exclude organic causes such as [[lactose intolerance]], [[celiac disease]]<nowiki/>and [[Inflammatory bowel disease|IBD]] and help make a positive diagnosis of [[Irritable bowel syndrome|IBS]] while avoiding unnecessary investigations.
###Plain film of [[abdomen]]


The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].
Evolution of the Rome IV criteria:
* In 1978, the first [[Diagnosis|diagnostic criteria]] ([[Manning criteria|Manning criteria)]] was published. [[Manning criteria]] has a [[Sensitivity (tests)|sensitivity]] of 78% and [[Specificity (tests)|specificity]] of 72%.<ref name="pmid698649">{{cite journal |vauthors=Manning AP, Thompson WG, Heaton KW, Morris AF |title=Towards positive diagnosis of the irritable bowel |journal=Br Med J |volume=2 |issue=6138 |pages=653–4 |year=1978 |pmid=698649 |pmc=1607467 |doi= |url=}}</ref><ref name="pmid2318433">{{cite journal |vauthors=Talley NJ, Phillips SF, Melton LJ, Mulvihill C, Wiltgen C, Zinsmeister AR |title=Diagnostic value of the Manning criteria in irritable bowel syndrome |journal=Gut |volume=31 |issue=1 |pages=77–81 |year=1990 |pmid=2318433 |pmc=1378344 |doi= |url=}}</ref>
* Kruis criteria published in 1984 has a [[Sensitivity (tests)|sensitivity]] (77%) and [[Specificity (tests)|specificity]] (89%). <ref name="pmid6724251">{{cite journal |vauthors=Kruis W, Thieme C, Weinzierl M, Schüssler P, Holl J, Paulus W |title=A diagnostic score for the irritable bowel syndrome. Its value in the exclusion of organic disease |journal=Gastroenterology |volume=87 |issue=1 |pages=1–7 |year=1984 |pmid=6724251 |doi= |url=}}</ref>
* 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 (tests)|sensitivity]] of 71% and [[Specificity (tests)|specificity]] of 85%.The Rome Ⅲ criteria have a [[Sensitivity (tests)|sensitivity]] of 75%.<ref name="pmid20179688">{{cite journal |vauthors=Whitehead WE, Drossman DA |title=Validation of symptom-based diagnostic criteria for irritable bowel syndrome: a critical review |journal=Am. J. Gastroenterol. |volume=105 |issue=4 |pages=814–20; quiz 813, 821 |year=2010 |pmid=20179688 |pmc=3856202 |doi=10.1038/ajg.2010.56 |url=}}</ref><ref name="pmid29072609">{{cite journal |vauthors=Lacy BE, Patel NK |title=Rome Criteria and a Diagnostic Approach to Irritable Bowel Syndrome |journal=J Clin Med |volume=6 |issue=11 |pages= |year=2017 |pmid=29072609 |doi=10.3390/jcm6110099 |url=}}</ref><ref name="pmid27477090">{{cite journal |vauthors=Saps M, van Tilburg MA, Lavigne JV, Miranda A, Benninga MA, Taminiau JA, Di Lorenzo C |title=Recommendations for pharmacological clinical trials in children with irritable bowel syndrome: the Rome foundation pediatric subcommittee on clinical trials |journal=Neurogastroenterol. Motil. |volume=28 |issue=11 |pages=1619–1631 |year=2016 |pmid=27477090 |doi=10.1111/nmo.12896 |url=}}</ref><ref name="pmid10457044">{{cite journal |vauthors=Thompson WG, Longstreth GF, Drossman DA, Heaton KW, Irvine EJ, Müller-Lissner SA |title=Functional bowel disorders and functional abdominal pain |journal=Gut |volume=45 Suppl 2 |issue= |pages=II43–7 |year=1999 |pmid=10457044 |pmc=1766683 |doi= |url=}}</ref><ref name="FASS_2001">{{cite journal |author=Fass R, Longstreth GF, Pimentel M, ''et al''|title=Evidence- and consensus-based practice guidelines for the diagnosis of irritable bowel syndrome |journal=Arch. Intern. Med.|volume=161 |issue=17 |pages=2081-8 |year=2001 |pmid=11570936 |doi=}}</ref>


OR
* Rome Ⅱ states that a patient must have [[Abdominal pain|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 [[Human feces|stool]] frequency,  relief with [[defecation]], change in [[Human feces|stool]] form.<ref name="pmid23419383">{{cite journal |vauthors=Engsbro AL, Begtrup LM, Kjeldsen J, Larsen PV, de Muckadell OS, Jarbøl DE, Bytzer P |title=Patients suspected of irritable bowel syndrome--cross-sectional study exploring the sensitivity of Rome III criteria in primary care |journal=Am. J. Gastroenterol. |volume=108 |issue=6 |pages=972–80 |year=2013 |pmid=23419383 |doi=10.1038/ajg.2013.15 |url=}}</ref><ref name="pmid24944467">{{cite journal |vauthors=Saha L |title=Irritable bowel syndrome: pathogenesis, diagnosis, treatment, and evidence-based medicine |journal=World J. Gastroenterol. |volume=20 |issue=22 |pages=6759–73 |year=2014 |pmid=24944467 |pmc=4051916 |doi=10.3748/wjg.v20.i22.6759 |url=}}</ref>
* Rome Ⅲ states that a patient must have recurrent [[Abdominal pain|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 [[Human feces|stool]] frequency,  change in [[Human feces|stool]] consistency. or improvement with [[defecation]].<ref name="pmid23419383">{{cite journal |vauthors=Engsbro AL, Begtrup LM, Kjeldsen J, Larsen PV, de Muckadell OS, Jarbøl DE, Bytzer P |title=Patients suspected of irritable bowel syndrome--cross-sectional study exploring the sensitivity of Rome III criteria in primary care |journal=Am. J. Gastroenterol. |volume=108 |issue=6 |pages=972–80 |year=2013 |pmid=23419383 |doi=10.1038/ajg.2013.15 |url=}}</ref><ref name="pmid22632582">{{cite journal |vauthors=Dang J, Ardila-Hani A, Amichai MM, Chua K, Pimentel M |title=Systematic review of diagnostic criteria for IBS demonstrates poor validity and utilization of Rome III |journal=Neurogastroenterol. Motil. |volume=24 |issue=9 |pages=853–e397 |year=2012 |pmid=22632582 |doi=10.1111/j.1365-2982.2012.01943.x |url=}}</ref>


The diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 3].
* In 2006, criteria based on pharmacological studies were laid down: It required spontaneous [[Defecation|bowel movements]] 3 times per week and one of the following [[Symptom|symptoms]] for at least 12 weeks during the past 12 months: <ref name="pmid26245951">{{cite journal |vauthors=Lau M, Ford AC |title=Constipation in adults |journal=BMJ Clin Evid |volume=2015 |issue= |pages= |year=2015 |pmid=26245951 |pmc=4526959 |doi= |url=}}</ref><ref name="pmid23261065">{{cite journal |vauthors=Bharucha AE, Pemberton JH, Locke GR |title=American Gastroenterological Association technical review on constipation |journal=Gastroenterology |volume=144 |issue=1 |pages=218–38 |year=2013 |pmid=23261065 |pmc=3531555 |doi=10.1053/j.gastro.2012.10.028 |url=}}</ref><ref name="pmid16678561">{{cite journal |vauthors=Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC |title=Functional bowel disorders |journal=Gastroenterology |volume=130 |issue=5 |pages=1480–91 |year=2006 |pmid=16678561 |doi=10.1053/j.gastro.2005.11.061 |url=}}</ref><ref name="pmid20045700">{{cite journal |vauthors=Lembo AJ, Kurtz CB, Macdougall JE, Lavins BJ, Currie MG, Fitch DA, Jeglinski BI, Johnston JM |title=Efficacy of linaclotide for patients with chronic constipation |journal=Gastroenterology |volume=138 |issue=3 |pages=886–95.e1 |year=2010 |pmid=20045700 |doi=10.1053/j.gastro.2009.12.050 |url=}}</ref><ref name="pmid20801122">{{cite journal |vauthors=Johnston JM, Kurtz CB, Macdougall JE, Lavins BJ, Currie MG, Fitch DA, O'Dea C, Baird M, Lembo AJ |title=Linaclotide improves abdominal pain and bowel habits in a phase IIb study of patients with irritable bowel syndrome with constipation |journal=Gastroenterology |volume=139 |issue=6 |pages=1877–1886.e2 |year=2010 |pmid=20801122 |doi=10.1053/j.gastro.2010.08.041 |url=}}</ref>
** Straining in one-fourth or more of [[defecation]]  
** Lumpy or hard [[Human feces|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 cycle|menstrual]] [[abdominal pain]] or discomfort 
** A mean of 3 complete spontaneous [[Bowel movement|bowel movements]] and >6 [[Bowel movement|spontaneous bowel movements]] per week


OR
* In 2009, [[American College of Gastroenterology Guidelines|American College of Gastroenterology (ACG]]) stated that no criteria based on [[symptoms]] could have accuracy for the [[diagnosis]] of [[Irritable bowel syndrome|IBS]]. It defined [[Irritable bowel syndrome|IBS]] as [[Abdominal pain|pain in the abdomen]] or discomfort that was in association with altered [[Intestine|bowel]] habits over at least 3 months.<ref name="pmid19521341">{{cite journal |vauthors=Brandt LJ, Chey WD, Foxx-Orenstein AE, Schiller LR, Schoenfeld PS, Spiegel BM, Talley NJ, Quigley EM |title=An evidence-based position statement on the management of irritable bowel syndrome |journal=Am. J. Gastroenterol. |volume=104 Suppl 1 |issue= |pages=S1–35 |year=2009 |pmid=19521341 |doi=10.1038/ajg.2008.122 |url=}}</ref><ref name="pmid25069544">{{cite journal |vauthors=Sood R, Law GR, Ford AC |title=Diagnosis of IBS: symptoms, symptom-based criteria, biomarkers or 'psychomarkers'? |journal=Nat Rev Gastroenterol Hepatol |volume=11 |issue=11 |pages=683–91 |year=2014 |pmid=25069544 |doi=10.1038/nrgastro.2014.127 |url=}}</ref><ref name="YAWN_20012">{{cite journal |author=Yawn BP, Lydick E, Locke GR, Wollan PC, Bertram SL, Kurland MJ|title=Do published guidelines for evaluation of irritable bowel syndrome reflect practice? |journal=BMC gastroenterology |volume=1|issue= |pages=11 |year=2001 |pmid=11701092 |doi=}}</ref> 
* The [[American Gastroenterological Association]] has published a set of guidelines for tests which physicians should perform prior to diagnosing [[irritable bowel syndrome]].<ref name="YAWN_2001">{{cite journal |author=Yawn BP, Lydick E, Locke GR, Wollan PC, Bertram SL, Kurland MJ |title=Do published guidelines for evaluation of irritable bowel syndrome reflect practice? |journal=BMC gastroenterology|volume=1 |issue= |pages=11 |year=2001 |pmid=11701092 |doi=}}</ref>  The following tests are meant to exclude other causes, such as [[infection]] and [[colon cancer]].
*#[[History and Physical examination|History and physical examination]]
*#[[Diagnosis|Diagnostic]] testing
*##[[Complete blood count|CBC]]
*##Chemistry panel
*##[[Erythrocyte sedimentation rate|Sedimentation rate]]
*##Stool for [[ova]] & [[parasites]]
*##[[Stool]] for [[occult blood]]
*##Flexible [[sigmoidoscopy]]
*##IF > 50, [[colonoscopy]] or [[Lower gastrointestinal series|barium enema]] and [[sigmoidoscopy]]
*##For [[diarrhea]] predominant:
*###[[Small bowel]] [[Radiography|radiograph]]
*###[[Lactose]]/[[dextrose]] [[Hydrogen Breath Test|hydrogen breathing test]]
*##For [[constipation]] predominant:
*###Fiber trial 
*###For [[pain]] predominant:
*#Plain film of [[abdomen]]
* Difference between Rome III and IV criteria: <ref name="pmid28672432">{{cite journal |vauthors=Ghoshal UC |title=Pros and Cons While Looking Through an Asian Window on the Rome IV Criteria for Irritable Bowel Syndrome: Pros |journal=J Neurogastroenterol Motil |volume=23 |issue=3 |pages=334–340 |year=2017 |pmid=28672432 |pmc=5503282 |doi=10.5056/jnm17020 |url=}}</ref><ref name="pmid28643273">{{cite journal |vauthors=Ghoshal UC |title=Chronic constipation in Rome IV era: The Indian perspective |journal=Indian J Gastroenterol |volume=36 |issue=3 |pages=163–173 |year=2017 |pmid=28643273 |doi=10.1007/s12664-017-0757-1 |url=}}</ref><ref name="pmid28374308">{{cite journal |vauthors=Simren M, Palsson OS, Whitehead WE |title=Update on Rome IV Criteria for Colorectal Disorders: Implications for Clinical Practice |journal=Curr Gastroenterol Rep |volume=19 |issue=4 |pages=15 |year=2017 |pmid=28374308 |pmc=5378729 |doi=10.1007/s11894-017-0554-0 |url=}}</ref><ref name="pmid28303651">{{cite journal |vauthors=Tack J, Drossman DA |title=What's new in Rome IV? |journal=Neurogastroenterol. Motil. |volume=29 |issue=9 |pages= |year=2017 |pmid=28303651 |doi=10.1111/nmo.13053 |url=}}</ref><ref name="pmid22632582">{{cite journal |vauthors=Dang J, Ardila-Hani A, Amichai MM, Chua K, Pimentel M |title=Systematic review of diagnostic criteria for IBS demonstrates poor validity and utilization of Rome III |journal=Neurogastroenterol. Motil. |volume=24 |issue=9 |pages=853–e397 |year=2012 |pmid=22632582 |doi=10.1111/j.1365-2982.2012.01943.x |url=}}</ref><ref name="pmid27144617">{{cite journal |vauthors=Drossman DA |title=Functional Gastrointestinal Disorders: History, Pathophysiology, Clinical Features and Rome IV |journal=Gastroenterology |volume= |issue= |pages= |year=2016 |pmid=27144617 |doi=10.1053/j.gastro.2016.02.032 |url=}}</ref>
** The definition of [[Irritable bowel syndrome|IBS]] is recurrent [[abdominal pain]] associated with a change in frequency and/or form of the [[Human feces|stool]].
**  Rome IV defines IBS as a disorder of [[Gut tract|gut]]-[[brain]] interaction as opposed to being a functional disorder of the [[Gastrointestinal tract|GI tract.]]
** The Rome III criteria mentioned the term “[[Abdomen|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 [[Irritable bowel syndrome|IBS]] patients may report worsening of [[pain]] following [[defecation]].<ref name="pmid23449495">{{cite journal |vauthors=Occhipinti K, Smith JW |title=Irritable bowel syndrome: a review and update |journal=Clin Colon Rectal Surg |volume=25 |issue=1 |pages=46–52 |year=2012 |pmid=23449495 |pmc=3348735 |doi=10.1055/s-0032-1301759 |url=}}</ref>
** Rome IV states that some [[Symptom|symptoms]] must be present for at least 6 months and that patients must meet the criteria for at least 3 months before [[Irritable bowel syndrome|IBS]] is [[Diagnosis|diagnosed]].
** Experts state that physicians should limit evaluation to Rome criteria fulfillment if no alarm [[Symptom|symptoms]] are present.<ref name="pmid14502111">{{cite journal |vauthors=Olden KW |title=The challenge of diagnosing irritable bowel syndrome |journal=Rev Gastroenterol Disord |volume=3 Suppl 3 |issue= |pages=S3–11 |year=2003 |pmid=14502111 |doi= |url=}}</ref>
==== The comparison table for diagnostic studies of choice for IBS<ref name="pmid20179688" /><ref name="pmid23994201">{{cite journal |vauthors=Ford AC, Bercik P, Morgan DG, Bolino C, Pintos-Sanchez MI, Moayyedi P |title=Validation of the Rome III criteria for the diagnosis of irritable bowel syndrome in secondary care |journal=Gastroenterology |volume=145 |issue=6 |pages=1262–70.e1 |year=2013 |pmid=23994201 |doi=10.1053/j.gastro.2013.08.048 |url=}}</ref>  ====
{|
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
! style="background: #FFFFFF; color: #FFFFFF; text-align: center;" |C
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Sensitivity
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Specificity
|-
! style="background: #696969; color: #FFFFFF; text-align: center;" |Rome Ⅲ
| style="background: #DCDCDC; padding: 5px; text-align: center;" |75% <small>✔</small>
| style="background: #DCDCDC; padding: 5px; text-align: center;" |85%
|-
! style="background: #696969; color: #FFFFFF; text-align: center;" |Rome IV
| style="background: #DCDCDC; padding: 5px; text-align: center;" |62%
| style="background: #DCDCDC; padding: 5px; text-align: center;" |97% <small>✔</small>
|}
<small> ✔= The best test based on the feature </small>


The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].
===== 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 [[Human feces|stool]] frequency, change in [[Human feces|stool]] appearance or [[Pain]] related to [[defecation]]. In addition, the patient must have none of the following warning [[Signs and Symptoms|signs]] as the first step of diagnosis.
* Physicians should limit evaluation to Rome IV criteria fulfillment if no alarm [[Symptom|symptoms]] are present.


OR
* All the criteria described for [[Irritable bowel syndrome|IBS]] are listed below in reverse chronological order:
 
There are no established criteria for the diagnosis of [disease name].
* All the criteria described for IBS are listed below in reverse chronological order:
{| class="wikitable"
{| class="wikitable"
! align="center" style="background: #4479BA; color: #FFFFFF; " |Diagnostic criteria
! align="center" style="background: #4479BA; color: #FFFFFF; " |Diagnostic criteria
! align="center" style="background: #4479BA; color: #FFFFFF; " |Symptoms, signs and labs
! align="center" style="background: #4479BA; color: #FFFFFF; " |Symptoms, signs and labs
|-
|-
|style="background: #DCDCDC; text-align: center;" |2016: Rome IV
| style="background: #DCDCDC; text-align: center;" |2016: Rome IV<ref name="pmid28574520">{{cite journal |vauthors=Heidelbaugh JJ |title=These 3 tools can help you streamline management of IBS |journal=J Fam Pract |volume=66 |issue=6 |pages=346–353 |year=2017 |pmid=28574520 |doi= |url=}}</ref>
|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-
|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:
[[Pain in the abdomen]] must be associated with at least two of the following:
# Change in stool frequency
# Change in [[Human feces|stool]] frequency
# Change in stool appearance or form
# Change in [[Human feces|stool]] appearance or form
# Pain related to defecation
# [[Pain]] related to [[defecation]]
Patient must have none of the following warning signs:
Patient must have none of the following warning [[Signs and Symptoms|signs]]:
# Unintentional loss of weight
# Unintentional [[Weight loss|loss of weight]]
# Age ≥50 years, without previous colon cancer screening
# Age ≥50 years, without previous [[Colorectal cancer|colon cancer]] [[Screening (medicine)|screening]]
# Recent change in bowel habit
# Recent change in bowel habit
# Hematochezia or melena i.e. evidence of overt gastrointestinal bleeding
# [[Hematochezia]] or [[melena]] i.e. evidence of overt [[gastrointestinal bleeding]]
# Nocturnal pain in the abdomen or passage of stools
# Nocturnal [[Abdominal pain|pain in the abdomen]] or passage of [[Human feces|stools]]
# History of inflammatory bowel disease or colorectal cancer in the family
# History of [[inflammatory bowel disease]] or [[colorectal cancer]] in the family
# Palpable abdominal mass or presence of lymphadenopathy
# Palpable [[abdominal mass]] or presence of [[lymphadenopathy]]
# Positive fecal occult blood test
# Positive [[Fecal occult blood|fecal occult blood test]]
# Blood testing showing evidence of iron deficiency anemia
# [[Blood]] testing showing evidence of [[iron deficiency anemia]]
|-
|-
|style="background: #DCDCDC; text-align: center;" |2006: Rome Ⅲ
| style="background: #DCDCDC; text-align: center;" |2006: Rome Ⅲ<ref name="pmid23419383">{{cite journal |vauthors=Engsbro AL, Begtrup LM, Kjeldsen J, Larsen PV, de Muckadell OS, Jarbøl DE, Bytzer P |title=Patients suspected of irritable bowel syndrome--cross-sectional study exploring the sensitivity of Rome III criteria in primary care |journal=Am. J. Gastroenterol. |volume=108 |issue=6 |pages=972–80 |year=2013 |pmid=23419383 |doi=10.1038/ajg.2013.15 |url=}}</ref><ref name="pmid23449495">{{cite journal |vauthors=Occhipinti K, Smith JW |title=Irritable bowel syndrome: a review and update |journal=Clin Colon Rectal Surg |volume=25 |issue=1 |pages=46–52 |year=2012 |pmid=23449495 |pmc=3348735 |doi=10.1055/s-0032-1301759 |url=}}</ref>
|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)
|Recurrent [[Abdominal pain|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)
#   Onset of symptoms associated with a change in stool form(alternating between diarrhea and constipation)
#  Onset of [[symptoms]] associated with a change in [[Human feces|stool]] form (alternating between [[diarrhea]] and [[constipation]])
#  Onset of symptoms associated with a change in stool frequency  
#  Onset of [[symptoms]] associated with a change in [[Human feces|stool]] frequency  
#   Improvement with defecation  
#   Improvement with [[defecation]]
#   Absence of evidence of anatomic, inflammatory, neoplastic or metabolic causes to explain the symptoms
#   Absence of evidence of [[Anatomy|anatomic]], [[Inflammation|inflammatory]], [[Neoplasm|neoplastic]] or metabolic causes to explain the [[Symptom|symptoms]]
|-
|-
|style="background: #DCDCDC; text-align: center;" |1999: Rome Ⅱ  
| style="background: #DCDCDC; text-align: center;" |1999: Rome Ⅱ <ref name="pmid23419383">{{cite journal |vauthors=Engsbro AL, Begtrup LM, Kjeldsen J, Larsen PV, de Muckadell OS, Jarbøl DE, Bytzer P |title=Patients suspected of irritable bowel syndrome--cross-sectional study exploring the sensitivity of Rome III criteria in primary care |journal=Am. J. Gastroenterol. |volume=108 |issue=6 |pages=972–80 |year=2013 |pmid=23419383 |doi=10.1038/ajg.2013.15 |url=}}</ref><ref name="pmid24944467">{{cite journal |vauthors=Saha L |title=Irritable bowel syndrome: pathogenesis, diagnosis, treatment, and evidence-based medicine |journal=World J. Gastroenterol. |volume=20 |issue=22 |pages=6759–73 |year=2014 |pmid=24944467 |pmc=4051916 |doi=10.3748/wjg.v20.i22.6759 |url=}}</ref>
|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:
|[[Abdominal pain|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:
# Onset associated with a change in stool form  
# Onset associated with a change in [[Human feces|stool]] form  
# Onset associated with alterations in stool frequency  
# Onset associated with alterations in [[Human feces|stool]] frequency  
# Relief with defecation
# Relief with [[defecation]]
|-
|-
|style="background: #DCDCDC; text-align: center;" |1990: Rome Ⅰ
| style="background: #DCDCDC; text-align: center;" |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):
|[[Abdominal]] discomfort or [[pain]] relieved with defecation or associated with change in frequency or consistency of [[Human feces|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
1.     Altered [[Human feces|stool]] form


2.     Altered stool frequency
2.     Altered [[Human feces|stool]] frequency


3.     Altered stool passage
3.     Altered [[Human feces|stool]] passage


4.     Passage of mucus in stool
4.     Passage of [[mucus]] in [[Human feces|stool]]


5.     Abdominal bloating or distension
5.     Abdominal [[bloating]] or [[distension]]
|-
|-
|style="background: #DCDCDC; text-align: center;" |1984: Kruis
| style="background: #DCDCDC; text-align: center;" |1984: Kruis <ref name="pmid6724251">{{cite journal |vauthors=Kruis W, Thieme C, Weinzierl M, Schüssler P, Holl J, Paulus W |title=A diagnostic score for the irritable bowel syndrome. Its value in the exclusion of organic disease |journal=Gastroenterology |volume=87 |issue=1 |pages=1–7 |year=1984 |pmid=6724251 |doi= |url=}}</ref>
|Symptoms of IBS must be present for more than two years. These symptoms include the following:
|[[Symptoms]] of [[Irritable bowel syndrome|IBS]] must be present for more than two years. These symptoms include the following:


1.     Pain in the abdomen, flatulence  
1.     [[Abdominal pain|Pain in the abdomen]], [[flatulence]]


2.     Alternating constipation and diarrhea
2.     Alternating [[constipation]] and [[diarrhea]]


Signs that exclude IBS are determined by the physician. They are as follows:
[[Medical sign|Signs]] that exclude [[Irritable bowel syndrome|IBS]] are determined by the physician. They are as follows:


1.     Abnormal physical findings and/or history suggestive of any other diagnosis  
1.     Abnormal physical findings and/or history suggestive of any other diagnosis  


2.     ESR more than 20mm/2h  
2.     [[Erythrocyte sedimentation rate|ESR]] more than 20mm/2h  


3.     Anemia(Hemoglobin < 12 for women or < 14 for men)
3.     [[Anemia]] ([[hemoglobin]] < 12 mg/dl for women or < 14 mg/dl for men)


4.     Leukocytosis > 10000/cc
4.     [[Leukocytosis]] > 10000/cc


5.     Bleeding per rectum found on physical exam
5.     [[Bleeding]] per [[rectum]] found on [[Physical examination|physical exam]]
|-
|-
|style="background: #DCDCDC; text-align: center;" |1978: Manning  
| style="background: #DCDCDC; text-align: center;" |1978: Manning <ref name="pmid698649">{{cite journal |vauthors=Manning AP, Thompson WG, Heaton KW, Morris AF |title=Towards positive diagnosis of the irritable bowel |journal=Br Med J |volume=2 |issue=6138 |pages=653–4 |year=1978 |pmid=698649 |pmc=1607467 |doi= |url=}}</ref>
|A threshold of at least three positive symptoms needs to be present to diagnose IBS with no duration of symptoms described under this classification.
|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
1)     Loose [[Human feces|stools]] with onset of [[pain]]


2)     Increased frequency of stools with onset of pain
2)     Increased frequency of [[Human feces|stools]] with onset of pain


3)     Mucus per rectum
3)     [[Mucus]] per [[rectum]]


4)     Visible distension of abdomen reported by the patient
4)     Visible distension of [[abdomen]] reported by the patient


5)     Pain in the abdomen relieved by defecation
5)     [[Abdominal pain|Pain in the abdomen]] relieved by [[defecation]]


6)     Sensation of incomplete evacuation
6)     [[Sensation]] of incomplete evacuation
|}
|}


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{{WS}}
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[[Category: (name of the system)]]
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Latest revision as of 16:54, 3 December 2017

Irritable bowel syndrome Microchapters

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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]

Patient must have none of the following warning signs:

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:

  • 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]

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:

  1. Change in stool frequency
  2. Change in stool appearance or form
  3. Pain related to defecation

Patient must have none of the following warning signs:

  1. Unintentional loss of weight
  2. Age ≥50 years, without previous colon cancer screening
  3. Recent change in bowel habit
  4. Hematochezia or melena i.e. evidence of overt gastrointestinal bleeding
  5. Nocturnal pain in the abdomen or passage of stools
  6. History of inflammatory bowel disease or colorectal cancer in the family
  7. Palpable abdominal mass or presence of lymphadenopathy
  8. Positive fecal occult blood test
  9. Blood testing showing evidence of iron deficiency anemia
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)
  1.  Onset of symptoms associated with a change in stool form (alternating between diarrhea and constipation)
  2.  Onset of symptoms associated with a change in stool frequency
  3.   Improvement with defecation
  4.   Absence of evidence of anatomic, inflammatory, neoplastic or metabolic causes to explain the symptoms
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:
  1. Onset associated with a change in stool form
  2. Onset associated with alterations in stool frequency
  3. Relief with defecation
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

4.     Passage of mucus in stool

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

3)     Mucus per rectum

4)     Visible distension of abdomen reported by the patient

5)     Pain in the abdomen relieved by defecation

6)     Sensation of incomplete evacuation

References

  1. ↑ 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. ↑ 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.
  3. ↑ 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. ↑ 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. ↑ 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.
  6. ↑ 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.
  7. ↑ 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.
  8. ↑ 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.
  9. ↑ 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. ↑ 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. ↑ 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. ↑ 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.
  13. ↑ Lau M, Ford AC (2015). "Constipation in adults". BMJ Clin Evid. 2015. PMC 4526959. PMID 26245951.
  14. ↑ 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.
  15. ↑ 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.
  16. ↑ 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.
  17. ↑ 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.
  18. ↑ 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.
  19. ↑ 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.
  20. ↑ 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.
  21. ↑ 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.
  22. ↑ 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.
  23. ↑ 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.
  24. ↑ 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.
  25. ↑ Tack J, Drossman DA (2017). "What's new in Rome IV?". Neurogastroenterol. Motil. 29 (9). doi:10.1111/nmo.13053. PMID 28303651.
  26. ↑ 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. ↑ 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.
  28. ↑ Olden KW (2003). "The challenge of diagnosing irritable bowel syndrome". Rev Gastroenterol Disord. 3 Suppl 3: S3–11. PMID 14502111.
  29. ↑ 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.
  30. ↑ Heidelbaugh JJ (2017). "These 3 tools can help you streamline management of IBS". J Fam Pract. 66 (6): 346–353. PMID 28574520.

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