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Rome IV Modifications May Improve IBS Diagnosis

The Rome IV criteria assist physicians in diagnosing functional gastrointestinal disorders (FGID) such as irritable bowel syndrome (IBS), but the wide-ranging symptoms included don’t do a good job of distinguishing all disorders. The Rome Foundation has proposed changes to ROME IV, including reduction in the required duration and frequency of symptoms, and a greater focus on whether symptoms are bothersome.

In a review published in Gastroenterology, researchers suggest that these changes can improve the accuracy of IBS diagnoses. The researchers maintain that Rome IV identifies IBS patients with severe symptoms and a high burden of psychological comorbidity.

The review authors analyzed data from two previous studies. One was a cross-sectional survey of 1,375 self-reported IBS patients in the United Kingdom. When the researchers applied Rome IV criteria versus the earlier Rome III criteria, the proportion of patients identified as having IBS dropped from 79% to 59%. Those identified with IBS by Rome IV had more severe symptoms and worse psychological health. When the researchers applied the modified Rome IV criteria for IBS to the cross-sectional survey, they found that 92.5% met the criteria. Compared to those who did not meet the criteria for IBS by the modified standard, those who did were more likely to have anxiety (49.0% versus 37.3%; P = .001), somatization (47.5% vs. 28.4%; P < .001), and gastrointestinal symptom-specific anxiety (33.8% vs. 15.7%; P < .001). There were no differences in the frequency of depression or severe symptoms.

In a second study, the researchers collected prospective data on 577 consecutive UK patients who visited an IBS clinic. Compared to the reference definition of IBS of lower abdominal pain with altered stool form or frequency, the Rome IV criteria had a sensitivity of 82.4% and a specificity of 82.9%. The positive likelihood ratio was 4.82 (95% confidence interval, 3.30-7.28) and the negative likelihood ratio was 0.21 (95% CI, 0.17-0.16). When the researchers applied the modified Rome IV criteria, 90.6% of patients were identified as having IBS. Compared to the reference standard, the sensitivity of modified Rome IV was 99.1%, and the specificity was 42.7%. The positive LR was 1.73 (95% CI, 1.48-2.02) and the negative LR was 0.02 (95% CI, 0.01-0.06).

Although the new data are of use to specialists, primary care physicians are often only vaguely aware of the Rome criteria, according to John Wilkinson, MD, who was asked to comment on the study. “As important as diagnosing IBS may be, it’s just as important to recognize that the patient has a FGID and does not benefit from continued testing, but rather naming the condition, reassuring the patient, and working together for ongoing self-management using primarily traditional interventions with proven track records,” said Wilkinson, a consultant in family medicine at the Mayo Clinic, Rochester, Minn.

He noted that physicians may be reluctant to make a diagnosis of IBS, in part because of pushback from patients who may feel that an IBS diagnosis is inadequate. “People have heard of it, usually, and often in a kind of a negative context. ‘Isn’t that the thing where they say that it’s all in your head?’ So, both doctors and patients are [not] particularly happy with the diagnosis.”

Nevertheless, making a diagnosis helps patients begin to manage their condition through diet and lifestyle changes. “I think the most important thing is to not continue to do testing, but talk to people about what they have, and then kind of move on (to management),” said Wilkinson.

Patients often go through periods of good health, with occasional flareups that result in urgent or emergency care. Tests often return normal results. “So, they are told a variety of things: There’s nothing wrong with you or we can’t find an answer. And this goes on and on over the years, and then finally somebody says, ‘Well, we can’t find an answer, so it must be irritable bowel,’ which is completely unsatisfactory,” said Wilkinson.

He feels that there is often an over-emphasis on testing and that physicians too often regard IBS as a disease of exclusion. “If it meets some general criteria, and you’ve excluded a few things, you don’t need to do other tests. The diagnosis of exclusion is an idea that is commonly held by a lot of physicians in primary care,” he said.

Wilkinson called for physicians to become more comfortable making a diagnosis of IBS, “and then be comfortable working with patients and explaining that this is a real thing. It isn’t imaginary. There’s a lot we don’t understand about it. There are things you can do to treat it, but it’s not exactly the model that most people think of where I go to the doctor, do a blood test that confirms that that’s what it is, and then you cure it. It’s a lot of work to have the conversation and work with these patients.”

The authors concluded that the modified criteria, with increased sensitivity even with less specificity, were useful. “The high sensitivity seen with the modified criteria means if these are not met at the outset, then a final diagnosis of IBS is highly unlikely, and further investigation should be pursued.” Further research is required to confirm the results.

The authors and Wilkinson have no relevant financial disclosures.

This article originally appeared on, part of the Medscape Professional Network.

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