Rome Process for Diagnosing IBS

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As I noted in the last post, the American Gastroenterological Association has published guidelines to assist in the diagnosis of irritable bowel syndrome (IBS). Another set of guidelines, known as the Rome II criteria, is also used by physicians to diagnose IBS.

The principal requirement for diagnosing IBS is abdominal pain. The Rome II criteria is used to diagnose IBS after a examining the patient’s medical history and conducting an examination of the abdomen. These are done to look for any ‘red flag’ symptoms.

According to the Rome II committees and the Functional Brain Gut Research Group, IBS can be diagnosed based on at least 12 weeks, which need not be consecutive, during the prior year that there was abdominal discomfort or pain that also exhibited two out of three features:

Relieved with defecation; and/or

Onset associated with a change in frequency of stool; and/or
Onset associated with a change in form (appearance) of stool.

Symptoms that cumulatively support the diagnosis of irritable bowel syndrome:

Abnormal stool frequency (for research purposes, “abnormal” may be defined as greater than 3 bowel movements per day and less than 3 bowel movements per week);
Abnormal stool form (lumpy/hard or loose/watery stool);
Abnormal stool passage (straining, urgency, or feeling of incomplete evacuation);
Bloating or feeling of abdominal distention.

Supportive symptoms of IBS:

A) Fewer than three bowel movements a week
B) More than three bowel movements a day
C) Hard or lumpy stools
D) Loose (mushy) or watery stools
E) Straining during a bowel movement
F) Urgency (having to rush to have a bowel movement)
G) Feeling of incomplete bowel movement
H) Passing mucus (white material) during a bowel movement
I) Abdominal fullness, bloating, or swelling

Diarrhea-predominant: At least 1 of B, D, F and none of A, C, E; or at least 2 of B, D, F and one of A or E.

Constipation-predominant: At least 1 of A, C, E and none of B, D, F; or at least 2 of A, C, E and one of B, D, F.

Red flag symptoms which are not typical of IBS:

Pain that awakens/interferes with sleep
Diarrhea that awakens/interferes with sleep
Blood in the stool (visible or occult)
Weight loss
Fever
Abnormal physical examination

In addition to meeting these positive criteria, patients have initial laboratory testing with a complete blood count, basic chemistry panel, and an erythrocyte sedimentation rate. Diagnostic accuracy for IBS is over 95% when Rome II criteria are met, history and physical exam do not suggest any other cause, and initial laboratory testing is negative.

In the past it was thought that the diagnosis of IBS relied on a diagnosis of exclusion; that is, if one cannot find a cause then IBS is the diagnosis. Currently the diagnosis of IBS relies on meeting Rome II inclusion criteria (updated by Rome III criteria) and excluding other illnesses based on history, physical exam, and laboratory testing. Although the Rome II and III criteria were not designed to be a management guideline, it is currently a “gold standard” for the diagnosis of IBS. Unfortunately, an IBS diagnosis in an adult patient is still only useful as a tool to rule out more serious problems unless further investigation is employed to discern an addressable condition.

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