Diagnostic Criteria for Functional Gastrointestinal Disorders

Introduction to Rome IV Criteria

The Rome IV criteria are the current gold standard for diagnosing functional GI disorders, requiring recurrent symptoms for at least 3 months with onset at least 6 months prior to diagnosis 1, 2

IBS requires recurrent abdominal pain at least 1 day per week in the last 3 months, with symptom onset at least 6 months before diagnosis, associated with two or more of the following: change in stool frequency, change in stool form/appearance 3, 4
The Manning criteria, a historical precursor, included six symptoms: abdominal pain relieved by defecation, looser stools with onset of pain, more frequent stools with onset of pain, abdominal distension, passage of mucus in stools, sensation of incomplete evacuation 5, 6, 4
Rome I criteria required at least 3 months of recurrent symptoms with abdominal pain/discomfort relieved with defecation or associated with change in stool frequency/consistency, plus two or more supportive features 5, 6, 4
Rome II criteria required 12 weeks or more in the last 12 months of abdominal discomfort/pain with two of three features: relieved by defecation, associated with change in frequency of stool, or associated with change in consistency of stool 5, 6, 4
Rome IV criteria are substantially more restrictive than Rome III, reducing global IBS prevalence from 10.1% to 4.1% 3, 2, 4
Rome IV identifies patients with more severe symptoms and higher psychological comorbidity compared to Rome III 3, 2, 4

Functional dyspepsia requires one or more bothersome symptoms (epigastric pain, epigastric burning, postprandial fullness, or early satiation) present for the last 3 months, with symptom onset at least 6 months before diagnosis, and no structural disease on upper endoscopy to explain symptoms 1, 2
"Bothersome" specifically means symptoms severe enough to impact usual activities 1, 2
Epigastric Pain Syndrome (EPS) requires one or both of the following at least 1 day per week: bothersome epigastric pain, bothersome epigastric burning 1, 2
Postprandial Distress Syndrome (PDS) requires one or both of the following at least 3 days per week: bothersome postprandial fullness, bothersome early satiation 1, 2
Upper endoscopy is required by definition to exclude structural disease in functional dyspepsia 1, 2

Rome IV has a separate category for abdominal bloating and distention, acknowledging this can be a primary disorder with a global prevalence as high as 3.5% (4.6% in women and 2.4% in men) 7
When Rome IV diagnostic criteria for functional abdominal bloating and distention are met, the patient should not fulfill criteria for IBS, functional constipation, functional diarrhea, or functional dyspepsia 7
Bloating and distention are much more prevalent (>50%) when associated with other disorders of gut-brain interaction 7

The diagnosis is more likely if the patient is female, aged <45 years with symptom history >2 years, and has attended frequently in the past with non-gastrointestinal symptoms 5, 6, 4
Warning signs mandating investigation regardless of age include: weight loss, rectal bleeding, nocturnal symptoms, or anemia 5, 6
If symptoms are atypical, history is short, or patient is over 45 years, perform further investigations including: sigmoidoscopy or colonoscopy, complete blood count to exclude anemia, thyroid function tests, antiendomysial antibodies, stool microscopy 5, 6