What Is New in Rome IV

Max J Schmulson, Douglas A Drossman, Max J Schmulson, Douglas A Drossman

Abstract

Functional gastrointestinal disorders (FGIDs) are diagnosed and classified using the Rome criteria; the criteria may change over time as new scientific data emerge. The Rome IV was released in May 2016. The aim is to review the main changes in Rome IV. FGIDs are now called disorders of gut-brain interaction (DGBI). Rome IV has a multicultural rather than a Western-culture focus. There are new chapters including multicultural, age-gender-women's health, intestinal microenvironment, biopsychosocial, and centrally mediated disorders. New disorders have been included although not truly FGIDs, but fit the new definition of DGBI including opioid-induced gastrointestinal hyperalgesia , opioid-induced constipation , and cannabinoid hyperemesis . Also, new FGIDs based on available evidence including reflux hypersensitivity and centrally mediated abdominal pain syndrome . Using a normative survey to determine the frequency of normal bowel symptoms in the general population changes in the time frame for diagnosis were introduced. For irritable bowel syndrome (IBS) only pain is required and discomfort was eliminated because it is non-specific, having different meanings in different languages. Pain is now related to bowel movements rather than just improving with bowel movements (ie, can get worse with bowel movement). Functional bowel disorders (functional diarrhea , functional constipation , IBS with predominant diarrhea [IBS-D], IBS with predominant constipation [IBS-C ], and IBS with mixed bowel habits ) are considered to be on a continuum rather than as independent entities. Clinical applications such as diagnostic algorithms and the Multidimensional Clinical Profile have been updated. The new Rome IV iteration is evidence-based, multicultural oriented and with clinical applications. As new evidence become available, future updates are expected.

Keywords: Constipation; Diarrhea; Functional gastrointestinal disorders; Irritable bowel syndrome; Rome IV.

Conflict of interest statement

Conflicts of interest: Max J Schmulson grant support: Alfa Wassermann, Nycomed/Takeda and Genova Diagnostics Inc; consultant/advisory board: Alfa Wassermann, Commonwealth Diagnostics International Inc, Takeda; speaker: Alfa Wasserman, Commowealth Diagnostics Inc, Mayoly-Spindler, Takeda. Douglas A Drossman is consultant/advisory board of Ironwood, Salix, and Abbvie.

Figures

Figure 1
Figure 1
Frequency of reporting of pain or burning above the belly button in the normative survey. The histograms show the frequency of reporting in different time frames for men, women and the combined sample. The vertical dotted line shows the 90th percentile for the combined sample of females and males. MT shows the minimum threshold in males and FT shows the minimum 90th percentile in females. Accordingly, a threshold of only 2–3 days a month would limit misclassification to 10% in females, whereas a threshold of 1 day/ month would limit misclassification to 10% in males. Reproduced with permission from Rome Foundation, Inc.
Figure 2
Figure 2
Different models to explain functional bowel/disorders of gut-brain interaction. (A) Rome I considered the functional bowel disorders as different and independent entities. (B) Later, Rome II-Rome III recognized that these disorders could overlap between the different functional bowel disorders. (C) Rome IV now considers that bowel disorders exist on a continuum rather than independent disorders. Adapted and reproduced from Whorwell et al with permission from Rome Foundation, Inc. IBS, irritable bowel syndrome; FC, functional constipation; FDr, functional diarrhea; C, constipation; D, diarrhea; M, mixed.
Figure 3
Figure 3
Changes in diagnostic criteria for irritable bowel syndrome (IBS) from Rome III to Rome IV. In Rome IV abdominal ‘discomfort’ has been deleted from the definition because of the imprecise nature of the term together with the fact that ‘discomfort’ is not present in every language; abdominal pain should be present at least 1 day a week on average during the preceding 3 months; ‘Improvement with’ defecation has been changed to ‘Related to’ defecation as in a subgroup of patients it may increase or remain without changes; and ‘Onset’ has been deleted from the associated changes in frequency and change in form (appearance) of stools. Adapted from Longstreth GF et al and Mearin F et al.

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