Perspective
The Con Argument

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Some claim that symptom-based Rome criteria are diagnostic and enhance clinical practice and choice of therapy for patients presenting with gastrointestinal symptoms. This overview focuses on lower gastrointestinal symptoms: constipation, diarrhea, pain, and bloating. The main con arguments for using such criteria for diagnosis are insufficient specificity, overlap of symptom-based categories or disorders, insufficient and therefore nonspecific characterization of pain in the criteria, inability to differentiate the “mimics” of irritable bowel syndrome (IBS) with constipation (IBS-C) and IBS with diarrhea (IBS-D), and inability to optimize treatment for IBS with mixed or alternating bowel function (IBS-M) or bloating in the absence of objective measurements.

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Limitations of the Symptom Phenotype in Irritable Bowel Syndrome

The Rome III “diagnostic” criteria for irritable bowel syndrome (IBS) are listed in Table 2.

Community-based questionnaire studies show that the subphenotypes of the FGIDs are not so distinct, with significant transition probability in patients classified with 1 condition identified at 1 point in time.2, 3

Data from large clinical samples question whether some entities are indeed different. Wong et al4 mailed 2 questionnaires 12 months apart to 1615 patients: 12.4% met Rome III criteria for

Pain and IBS Rome Criteria

Apart from the confusing “lumping” of pain and discomfort in the Rome criteria, there is not a single stereotypic pain quality or location in IBS. Rome criteria do not identify these differences nor reflect the fact that the pain may be secondary to bowel dysfunction.

A common complaint is chronic dull discomfort located in several regions overlying the colon during periods of constipation and relief of pain with bowel movements (BM) with different forms of constipation: IBS-C, FC, and

Sense of Incomplete Evacuation in the Definition of IBS-C

The Rome III definition of IBS includes “features of disordered defecation.” This may include a sense of incomplete evacuation and overlap with Rome III's “functional defecation disorders (FDD).” FDD result in symptoms that overlap with IBS-C: constipation, straining, sense of incomplete evacuation, bloating, and left-sided abdominal pain that is relieved by BM.

The Rome III definition of FDD requires at least 2 or more symptoms of impaired evacuation, inappropriate contraction of the pelvic

Conditions Mimicking IBS-D

In 94 patients with Rome III IBS-D, patient-defined diarrhea occurred in one fifth of the days and one fifth of the BM. Diarrhea BM were generally accompanied by urgency, pain, or discomfort, increase in other IBS symptoms, and stress.24 Several disorders or diseases mimic IBS-D (Table 3). Symptom criteria cannot identify those conditions, yet this is essential for optimal management of chronic diarrhea (Table 3). A few specific comments are pertinent.

First, bile acid malabsorption (BAM25) may

Objective Measurements Are Available to Supplement the History

In my clinical practice, physiologic tests (eg, radiopaque markers or scintigraphy for transit42, 43, 44, 45, 46 rather than symptoms alone) guide selection of therapy for patients. For example, prokinetic or secretagogue therapy is used in patients with slow transit constipation, and fiber and osmotic laxatives are used in patients with normal transit FC. Similarly, clonidine, alosetron, and octreotide are reserved for patients with unresponsive rapid transit diarrhea.

What Is the Treatment Target in Functional Bloating?

Functional bloating is typically diagnosed after constipation and sugar maldigestion are excluded. Bloating alone (not bloating with distension) is associated with rectal hypersensitivity, whereas bloating with distension (but not bloating alone) is associated with prolonged colonic transit (relative to patients with bloating alone).47, 48 In addition, reduction in abdominal girth occurs overnight, presumably as the pelvic floor and anal sphincter relaxation allows gas expulsion.49 In addition,

Is Symptom Criteria-Based “Diagnosis” Safe in IBS and Is There an Opportunity Cost?

The risk of significant organic disease is low, given the high prevalence of FGID among people in the community and patients attending gastroenterology or primary care clinics. This suggests that symptom-based, provisional diagnosis based on symptom criteria is reasonable in primary care. However, this approach may miss significant disease such as celiac sprue, colon cancer, and carcinoid diarrhea. Among 112 Olmsted County, Minnesota residents followed for a median of 15 years after diagnosis

Conclusions

“IBS” is a constellation of symptoms, a phenotype that may reflect a spectrum of underlying diseases/disorders. Symptom-based criteria lack the specificity that the clinician can obtain with a thorough history. Optimal management requires identification of the cause of symptoms.

In my practice, I optimize diagnosis through validated function tests (eg, spastic from flaccid functional defecation disorder, slow transit constipation, rapid transit diarrhea, bile acid malabsorption, and gluten or

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    • Conflict of interest The author discloses no conflicts.

    Funding Dr Camilleri's work in IBS is supported in part by DK-54681 from the National Institutes of Health.

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