OS Palsson et al. Gastoenterol 2020; 158: 1262-73. The authors note that the switch from Rome III to Rome IV criteria reduces the prevalence of IBS by half, but increases the prevalence of functional constipation and functional diarrhea.
Full text PDF: Prevalence of Rome IV Functional Bowel Disorders Among Adults in the United States, Canada, and the United Kingdom
BACKGROUND & AIMS:
Little is known about the population prevalence or demographic distributions of Rome IV functional bowel disorders (FBDs) or their effects on quality of life. We examined these in a multinational survey.
We analyzed data from a population-based [online] survey of adults in the United States, Canada, and United Kingdom (5931 valid responders; 49.2% female; mean age, 47.4 years; range, 18-92 years). The survey included the Rome IV Diagnostic Questionnaire, Rome III irritable bowel syndrome (IBS) and constipation questions, and the SF-8 quality of life questionnaire.
The prevalence values of census-adjusted Rome IV FBDs were similar among the 3 countries; ranges were: 4.4%-4.8% for IBS, 7.9%-8.6% for functional constipation, 3.6%-5.3% for functional diarrhea, 2.0%-3.9% for functional bloating or distention, 1.1%-1.9% for opioid-induced constipation, 7.5%-10.0% for unspecified FBDs, and 28.6%-31.7% for any Rome IV FBD. FBDs were less common in older individuals, and all except functional diarrhea were more common in women. IBS was only half as prevalent by Rome IV as by Rome III criteria (4.6% vs 9.0% overall), primarily due to higher Rome IV minimum pain frequency. Functional diarrhea and functional constipation were more prevalent by Rome IV than Rome III criteria. Subjects with FBD had significant reductions in quality of life and reported more gastrointestinal doctor consultations than other subjects.
More than 1 in 4 adults in the general population meet the Rome IV criteria for FBDs. These disorders affect quality of life and increase use of gastrointestinal health care. The switch from Rome III to Rome IV criteria reduces the prevalence of IBS by half, but increases the prevalence of functional constipation and functional diarrhea.
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From @EricTopol: Just published @TheLancet The largest study of hydroxychloroquine shows a significant increase in death (~35%) and >2-fold increase of serious heart arrhythmias. ~96,000 patients, ~15,000 on HCQ or CQ from 671 hospitals, 6 continents.
I want to thank the many people who have helped me with this blog –now with 2180 posts over more than 6 years. This includes my wife, my colleagues at GICareforKids, and colleagues from across the country who have provided critical feedback as well as useful publications to review. I hope this blog continues to be a useful resource.
Here are the top dozen most popular blog posts from 2017:
What are the changes in Rome IV for children and adolescents? JS Hyams, C DiLorenzo et al (Gastroenterol 2016; 150: 1456-68) provide a helpful review.
The ‘dictum’ that there was “no evidence for organic disease” as an criteria for functional disorders has been dropped in favor of “after appropriate medical evaluation the symptoms cannot be attributed to another medical condition.” This subtle change discourages excessive investigations.
The functional disorders covered in this article include
- H1 Functional nausea and vomiting disorders: H1a -cyclic vomiting syndrome, H1b -functional nausea and vomiting (NEW), H1c -rumination syndrome, H1d -aerophagia
- H2 Functional abdominal pain disorders: H2a -functional dyspepsia, H2b -irritable bowel syndrome, H2c -abdominal migraine, H2d -functional abdominal pain -not otherwise specified
- H3 Functional defecation disorders: H3a -functional constipation, H3b -nonretentive fecal incontinence
- “There are no published data on the treatment of isolated functional nausea and isolated functional vomiting”
- “We have eliminated the requirement of pain to fulfill the criteria for FD” [functional dyspepsia]
- Criteria for cyclic vomiting and abdominal migraines now require only 2 episodes in a 6 month period
- Criteria for functional constipation requires only 1 month rather than 2 months (this is true for H3b as well). The authors endorsed the NASPGHAN expert guidelines which included “no role for routine use of an abdominal x-ray to diagnose FC.” The guideline discourages testing for cow’s milk allergy, hypothyroidism, celiac disease and hypercalcemia in the absence of alarm symptoms.
In a separate article, MA Benninga, S Nurko et al (Gastroenterol 2016; 150: 1443-55) describe the functional disorders affecting infants and toddlers.
In my view, the article in this special edition that incorporates the most changes regards functional disorders of the biliary tree (FGBD) (PB Cotton et al Gastroenterol 2016; 150: 1420-29). This is mainly due to data showing that sphincterotomy is no better than sham treatment for patients with post-cholecystectomy pain. “The concept of sphincter of Oddi dysfunction type III is discarded.” In addition, for biliary pain/’gallbladder dyskinesia,’ the authors also acknowledge that the role of obtaining a gallbladder ejection fraction is “controversial.” “Symptoms suggestive of FGBD often resolve spontaneously so that early intervention is unwarranted.” Ultimately, the authors state that “treatment recommendations are not firmly evidence-based.”
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Owl in Our Neighborhood
When I visited MIT, one of the slogans I heard was “Getting an Education from MIT is like taking a drink from a Fire Hose.” While this is a ridiculous notion, it is also true that the amount of information to consume, not just at MIT, but in so many areas is tremendous in quantity. As such, one has to figure out what to read and what to toss. For GI physicians, a recent summary (DA Drossman. Gastroenterol 2016; 1262-80) is worth a read due to the ubiquitous nature of the problems discussed.
Here were some key points:
- “The possibility that passions or emotions could lead to the development of medical disease was first proposed by the Greek physician Claudius Galen.”
- “Rome IV is a compendium of knowledge accumulated since Rome III” –10 years ago.
Some of the Changes:
- New diagnoses: Narcotic bowel syndrome, opioid-induced constipation, cannabinoid hyperemesis syndrome
- Removal of functional terminology when possible…functional abdominal pain syndrome has been changed to centrally mediated abdominal pain syndrome
- Threshold changes for diagnostic criteria
- Addition of reflux hypersensitivity diagnosis.
- Revision of Sphincter of Oddi dysfunction disorder… “driven by evidence that debunks the value of sphincterotomy for type III SOD.”
- Emphasis that functional disorders exist on a spectrum with linked pathogenesis, particularly with regard to irritable bowel syndrome (IBS) subtypes.
- Removal of the term discomfort for IBS criteria and using pain as the key criterion.
Approach to Patients with Functional GI Disorders:
- The author discusses ways to engage patient to create partner-like interaction.
- “Determine the immediate reason for the patient’s visit (eg. What led you to see me at this time?)” Potential reasons: exacerbating factors, concern for serious disease, stressors, emotional comorbidity, impairment in daily functioning or hidden agenda (eg. disability, narcotics, litigation)
- “Determine what the patient understands of the illness…What do you think is causing your symptoms?”
- Provide a thorough explanation of the disorder. “For example: ‘I understand you believe you have an infection that has been missed; as we understand it, the infection is gone but your nerves have even affected by the infection to make you feel like it is still there, similar to phantom limb.”
- “Identify and respond realistically to the patient’s expectations for improvement (e.g. How do you feel I can be helpful to you?)”
- Explain ways that stress can be associated. “I understand you do not see stress as causing your pain, but you have mentioned how severe and disabling your pain is. How much do you think that is causing you emotional distress?”
- “Set consistent limits..narcotic medication is not indicated because it can be harmful.”
- “Involve patient in treatment plan (e.g. Let me suggest some treatments for you to consider).”
- With regard to use of TCAs, the author explains that antidepressants can be used “to turn down the pain, and pain benefit occurs in doses lower than that used for depression.” “Tricyclic antidepressants or the serotonin-norepinephrine reuptake inhibitors help control pain via central analgesia as well as provide relief of associated depressive symptoms. The selective serotonin reuptake inhibitors are less effective for pain but can help reduce anxiety and associated depression.”
- Establish an ongoing relationship. “Whatever the result of this treatment, I am prepared to consider other options, and I will continue to work with you through this.”
My take: This summary provides a succinct update on a 6-year effort of 117 investigators/clinicians from 23 countries. After reading this article, you will probably want to glance at the other articles in the same issue.
Vik Muniz Collage
A closer look at the front wheel