Rome III criteria

REVIEWS

Rome III: New Standard for Functional Gastrointestinal
Disorders
Douglas A Drossman1, Dan L Dumitrascu2

1) Douglas A Drossman, Division of Gastroenterology and Hepatology, UNC Center for Functional GI and Motility
Disorders, Chapel Hill, NC, USA. 2) Dan L Dumitrascu, 3rd Medical Department., University of Medicine and Pharmacy,
Cluj-Napoca, Romania

Abstract compiled into a book that was published in 1994 (5). The
criteria were then updated as Rome II in 2000 (6) and
The publication in the April, 2006 issue of published in abbreviated form as a supplement of Gut, 1999.
Gastroenterology of Rome III has made available to the
scientific world an enhanced and updated version of the
Rome criteria and related information on the functional GI
disorders. It is expected that the criteria will be adopted and The need for a new version of Rome criteria
used by physicians, pharmaceuticals and regulatory In recent years the interest in the FGIDs by gastro-
agencies worldwide, just as the previous Rome II became enterologists, internists, psychologists and family
the standard for clinical practice and research. In this issue physicians as well as attention by the general has grown
of J Gastrointestin Liver Dis, these Guidelines, the Rome III, considerably. This could be attributed to increased attention
are presented. Also included are some of the differences to these disorders by the media, pharmaceutical companies,
between Rome II and Rome III criteria as well as the rationale
academic and interest organizations like the International
for publishing this new version.
Foundation for Functional Gastrointestinal Disorders and
Key words the Functional Brain Gut Research Group of the American
Gastroenterological Association. But what has led to the
Functional gastrointestinal disorders - Rome III
development of another set of criteria: Rome III has several
explanations.
Introduction
Functional gastrointestinal disorders (FGID) represent
a common and important class of disorders within The availability of new data from scientific
gastroenterology. The large number of patients suffering progress
from the FGIDs, as well as the high frequency of functional The number of studies and publications on the FGID
GI symptoms in general within the population, the health increased along with the progress of newer investigative
care burden produced by the use of medical services and methods. In Fig 1 is presented the dynamics of the
medications for these conditions, and its eventual outcome publications on irritable bowel syndrome (IBS), a major
in terms of work absenteeism are well known (1-4). FGID, indexed on Medline. These studies served to
Quite possibly, increased awareness of the FGIDs may legitimize these conditions in a positive way, not just by
have resulted from the activity of the Rome working group, exclusion of other disorders. The assessment of motility
later called the Rome Foundation. This group introduced a has improved (7-9). The wider use of the barostat, as the
standard for the classification and diagnosis of the FGID, main technique for assessing visceral hypersensitivity has
the Rome criteria. A series of documents in the early 1990’s provided evidence for the role of visceral sensitivity in
published in Gastroenterology International was eventually understanding these conditions (10). Finally, another novel
J Gastrointestin Liver Dis area of development has been the progress in brain imaging:
September 2006 Vol.15 No.3, 237-241 positron emission tomography (PET), and functional
Address for correspondence: Douglas A Drossman magnetic resonance imaging (fMRI). These modalities offer
Division of Gastroenterol.Hepatol. a window into the central modulation of GI function and its
UNC Center for Functional GI
and Motility Disorders linkages to emotional and cognitive areas (11). Thus the
Chapel Hill, NC, USA nature of FGID as disorders of brain-gut interactions is now

In the last decades we have moved away product of the interaction of psychosocial factors and altered Fig. reductionistic model of disease. of emotions. the biopsychosocial model allows including antidepressants to treat stress-mediated effects for symptoms to be both physiologically multidetermined of CNS modulation of the gut (13-15). social support) and/or the development of gut dysfunction (i. . the FGID (16-17). Here. which in medicine. visceral The basic paradigm of the modern medicine has hypersensitivity. mucosal immunology. The newer agents include the 5-HT agonists and mind and body as part of a system where their dysregulation antagonists and several other gut receptor active agents can produce illness and disease. and cognitions have also been better illness (the person’s experience of ill health). and this refuted the traditional brain and gut peptides. inflammation. and these measures help us determine (objective histopathological findings) are viewed as equally the role of psychosocial factors on symptom generation important in understanding the clinical expression of a and health outcomes. of biological reductionism and dualism.e. all traditionally relied on the concepts promoted by Descartes of which lead to the clinical expression of the disorder. separation of mind and body at the time when society was accepting the concept of separation of church and state (19).. the concept of the mind (i. Finally. these brain-gut variables mutually interact to seeks to find a single biological etiology for every clinical influence their expression. visceral the mind was considered the seat of the soul. By embracing this for constipation and diarrhea. 21). The application of this model of Engel to the FGIDs helps to explain how changes in early life. psychological conceptualization state..1 Number of Medline indexed journal papers on IBS. pathology based on abnormal morphology). In addition. or altered bacterial flora). the central demands of patients now identified with FGIDs. different and modifiable by socio-cultural and psychosocial forms of psychotherapy have shown their benefit in treating influences (20. so disease was to develop new therapies defined by what was seen (i. stress.238 Drossman and Dumitrascu eminently amenable to scientific study. However. the molecular investigation of medical condition. coping skills. In recent nervous system. The reductionistic disease- and alterations in the bacterial flora of the gut provide the based biomedical model harmonized with Descartes’ translational basis for GI symptom generation. genetic factors and environmental factors. The psychological from this reductionistic model of disease to a more holistic instruments permitting the categorization and quantification paradigm of the biopsychosocial model of disease. and was not hypersensitivity. What resulted was permission to dissect the human The advent of new drugs and the necessity body (which was previously forbidden). may affect the psychosocial The shift of paradigm in medical development (susceptibility to life stress. CNS) as being amenable to scientific study years we have witnessed the development and release of or as playing a role in illness and disease was marginalized: new pharmacological agents to treat altered motility. and disease standardized (12).. This approach led to centuries of valuable There is a growing competition in the marketplace to research producing appropriated treatments for many synthesize and produce new medications to meet the diseases. inflammation. centrally acting agents integrated understanding. Furthermore.e.e. Therefore the FGID are the clinical condition (18). and stress-mediated effects in patients with to be tampered with. abnormal motility. More recent scientific studies link the FGID.

may not team committees to use a “Delphi” method of decision- perceive the need to seek medical care. continue to legitimize these disorders to society bowel disorders (category C) include IBS (C1).2 Chronology of the Rome criteria publications. For example. All physicians What is preserved in Rome III? now recognize the FGIDs as true clinical entities. role in categorizing and disseminating the new and evolving It maintains the principle of symptom-based diagnostic knowledge. functional constipation (C3) and functional Fig. Later. The publications of the Rome criteria in journals and books are presented in chronological order in Fig. bloating (C2). or maladaptive coping. television and even more on developmental stages for the pediatric neonate/ cinema. The undergraduate and postgraduate medical curricula. This classification is maintained in the pediatric increased dramatically. an The Rome process for developing these criteria is a individual with a bacterial gastroenteritis or other bowel rigorous one. and international symposia. Researchers and clinicians worldwide are more involved with these The Rome III classification has been printed in this issue disorders. in the having relatively specific clinical features. They are in order from esophagus of papers in the FGIDs in peer-reviewed journals has to anus. which fosters a team to produce consistency in with coexistent psychosocial comorbidities. and the translation of basic phageal (category A). or consensus (although not necessarily total abuse history. These disorders are now a prominent part of criteria like the DSM classification for mental disorders. The number presumably are produced. bowel neurotransmitter function into clinical symptoms and their (category C). gastroduodenal (category B). So. the beginning of the Rome process in 1989 (23). and the Rome process has played an important of J Gastrointestin Liver Dis in the section Guidelines. if it does develop. opinion. though is based are commonly reported in newspapers. But now there are future challenges to be faced: a toddler system. D). biliary (category E). functional (12). He charged working syndrome (or be aware of it) or.Rome III criteria 239 gut physiology via the brain-gut axis (22). Another individual making. clinical classification relies on the organs where the symptoms training programs. and anorectal (category F). The and visit more frequently the physician and have a worse Roma ’88 meeting led to the first presentation of criteria for clinical outcome. IBS. In a parallel fashion these disorders child/adolescent classification system. the From Rome II to Rome III Rome II committees and more recently the Rome III board took on the responsibility to enhance these activities using A great deal of progress in the field has evolved from a rigorous 4-year.2. The consensus process was initiated by disorder who has no concurrent psychosocial difficulties Professor Aldo Torsoli at the International Congress of and good coping skills may not develop the clinical Gastroenterology in Rome (Roma 1989). . multiple step process. functional abdominal pain syndrome (category impact on the patient’s health status and quality of life. There is also a need to educate clinicians and the general Each category site contains several disorders. each public on this rapidly growing knowledge and. may develop a FGID agreement) for difficult questions not easily addressed. which later evolved into a classification system for all the functional GI disorders (1) eventually evolving into the Rome criteria (Rome I) [reference Rome I book). the functional process. high life stress. need for an improved understanding of the relationships The FGIDs include 6 major domains for adults: eso- between mind and gut.

visceral hypersensitivity. there are situations where between these two categories relating to growth and a hierarchical classification of the FGIDs is required. or functional bloating (C2). and better treated (12). Examples would be Functional GI Disorders: Child/Adolescent (Category H)...240 Drossman and Dumitrascu diarrhea (C4). common to both these other conditions. functional Similarly functional bloating (C2) exists only when IBS and dyspepsia is de-emphasized as an entity for research due to the dyspeptic conditions are excluded. diarrhea. i. The Rome III classification system is 2. diagnostic and treatment approaches. The rationale for classifying the functional GI disorders b. There are several limitations and qualifications to the 3.Other diseases may coexist and have to be excluded. out of the need for diagnostic abnormalities within the GI tract. Postprandial distress syndrome. while symptoms (e. recommended to originate 6 months prior to diagnosis and The contribution of these factors may vary across different be currently active (i. Rumination syndrome moved from functional symptom clusters that “breed true” across clinical and esophageal (Category A) to functional gastroduodenal population groups. altered underway. and CNS-ENS dysregulation. IBS (C1) is more specifically defined as the consensus of experts in the field and have since been pain associated with change in bowel habit. changes in bacterial flora). bloating. where there provided in corresponding chapter of the Rome III book is no change in bowel habit.. and a diagnosis of Instead. fecal incontinence (category F1) may primarily be a disorder of The changes from Rome II to Rome III reflect mainly motor function. pain) may overlap across . This presumption provides a framework disorders (Category B). distinct from functional diarrhea (C4). and finally.e. For Rome III. Creation of two pediatric categories. IBS (category C1) is in the categories and criteria were made. colon. The pediatric and symptoms may overlap with other FGID.e. and this will form the basis for future mucosal immune and inflammatory function (which includes modifications of the criteria. mucosal immune dysregulation. and (b) Epigastric pain . a few modifications perception of normal visceral input. abdomen. which anatomically are attributed to the small . It is common FGID are now classified as Childhood Functional GI for functional GI disorders to coexist. combinations of their physiological determinants: increased . from epidemio- evidence that FAPS relates more to CNS amplification of logic data showing similar frequencies of these disorders normal regulatory visceral signals rather than functional across cultures. Removal of functional abdominal pain syndrome into symptom-based subgroups are based on the site- (FAPS) from functional bowel disorders (Category C) into specific differences between symptoms. recommendations for changes (e. Thus. dyspeptic criteria. meet criteria) for 3 months.. the fact that its own category (Category D).g. This is based on growing symptoms result from multiple influences. esophageal chest pain (A2) or globus (A4). the diagnosis of IBS only is 4. a.The proposed diagnostic criteria were originated by these disorders. while functional abdominal pain syndrome updates in the literature and committee recommendations (category D) is primarily understood as amplified central derived from these new data. enhanced visceral hypersensitivity. The Rome II use of symptom-based criteria: category of Childhood Functional GI Disorders (called . In some cases. In addition.g. This individuals or within the same individual over time. time frame is less restrictive when compared to Rome II (12 the clinical value of separating the functional GI symptoms weeks of symptoms over 12 months) and is easier to into discrete conditions is that they can be reliably diagnosed understand and apply in research and clinical practice. However. characterized by loose . standards in order to conduct clinical care and research.New criteria will be tested in future studies now motor reactivity. Thus. since bloating is the heterogeneity of this symptom complex as defined. criteria. For development of the child. These are: more complex. Symptoms are now alterations of bacterial flora. when criteria for both IBS (C1) and epigastric pain syndrome (B1b) are fulfilled. example. Changes in classification categories: based on the premise that for each disorder there are a. and this is modified only if there is compelling evidence to do so. subtypes of IBS) are not yet proven but The symptoms of the FGIDs are derived from are supported by compelling evidence. the committees recommend two conditions that are functional constipation (C3) is made only if IBS criteria are subsumed under the functional dyspepsia “umbrella”: (a) not met. Criteria changes: made when the epigastric pain is relieved by defecation. Change of chronological criteria. This reflects the evidence that this for identification of patients for research that is modified as disorder originates from disturbances in the stomach and new scientific data emerges.Diagnostic categories do not include psychosocial bowel.All changes in criteria relate to a rationale that is stools and no pain. and results from a combination of dysmotility. and rectum. For example. and the criteria permit Disorders: Neonate/Toddler (Category G) and Childhood the coexistence of more than one FGID. and altered CNS-enteric nervous system (ENS) regulation (as influenced by psychosocial and What has changed in Rome III? sociocultural factors and exposures). with IBS (C1) or This is due to the different clinical conditions that arise fecal incontinence (F1). Functional Dyspepsia. Category G) has been split into two categories. Each condition also has different chapter. 1. constipation.

147:535-544 3. Jones MP. Gastroenterology 2003. Alosetron in irritable bowel syndrome: strategies for the use in a common gastrointestinal It is expected that the new Rome III criteria will rapidly disorder. health care use and costs: a US managed care 23. Thompson WG. Talley NJ. et al.196:129-136 critical review of the literature on symptom and psychosocial 21. The committees are 224 recommending that diarrhea. However. Schoenfeld P.96:1340-1349 Am J Psychiatry 1980. Engel GL.63:1895-1905 gain acceptance and use as occurred with Rome II. Toner BB.42:223-241 consistency. The clinical application of the biopsychosocial model. Neurogastroenterol Motil 2005. 5. Saito YA. The cost-effectiveness on the FGID.3:159-172 19. Talley NJ. Crowel MD. connections in functional GI disorders: anatomic and Am J Gastroenterol 2002. Thompson WG. Drossman DA. However. et al.17: FGIDs.97: defining features and exclusions required for symptom-based 232-240 diagnosis of these conditions. Degnon Assoc McLean Virginia. In doing so. Delvaux M. Discours de la methode. Drossman DA. Whitehead WE Anorectal functional testig: the gallbladder and sphincter of Oddi. Thompson WG. These are similar to dysmotility-like and ulcer.Rome III criteria 241 syndrome. Talley NJ. Farraye FA. Gastroenterology 2003. Gut 2005. Kahrilas PJ. There is a need to validate the 15. Rome II: The functional gastrointestinal epigastric discomfort or pain respectively. Am J Gastroenterol 2003. et al. especially the postprandial distress syndrome.60:258-267 1990. Tayama J. Whitehead WE. Standardization procedures for testing smooth muscle tone and sensory thresholds in the subtypes be based on a simple classification related to stool gastrointestinal tract. Gut The members of the Rome Foundation hope that the 2004. Cognitive- References behavioral therapy vs. Locke GRI. Hasler WL.128:209-224 graphy (ERCP) and manometry to confirm the diagnosis and 9. Drossman DA. motor function in patients with irritable bowel syndrome. Descartes R. constipation and mixed 10.128:209- c. 2004. Pandolfino JE.98:600-607 2006. Corazziari E.125:19-31 Janssens J. Thompson like dyspepsia of Rome II. Guthrie E. Lembo A. Science 1977. Gastroenterology perspective. Sagami Y. Basic and clinical pharmacology of new become the new standard for diagnosis and care of the motility promoting agents. Drossman DA. Azpiroz F. Drossman DA. Revision of IBS subtypes criteria. Engel GL. Boyce PM. education and desipramine vs. papers and studies with Rome II criteria 643-653 will continue to be issued. Eck P. Dilley JB. disorders. Gastroenterology 2006. Identification of subgroups of 18. Vrin. et al. Weber HC. Am J Gastroenterol 2002.130:1377-1390 Conclusion 13. Longstreth GF. Corazziari E. Gastroenterology International the biopsychosocial model. they are now defined WG. of psychotherapy and paroxetine for severe irritable bowel syndrome. Whitehead WE. 1. centrally targeted treatments in IBS: a primer for predominant IBS (IBS-C) is still acceptable. Talley NJ. Funch-Jensen P. the bowel sub-typing used in Rome 11.18:91- 4. Effect of corticotrophin- new terms in non-Anglo-Saxon languages like the Latin releasing hormone receptor antagonist on colonic sensory and languages. Whitehead WE. Creed F. Irritable bowel 103 syndrome. Galligan JJ. Whitehead WE. Richter JE. Brain imaging and its implications for studying II for diarrhea-predominant IBS (IBS-D) and constipation. Neurogastroent Motil 2006. Little Brown 1994 rather than being based on the predominant symptom of 6. The road to Rome. AGA technical review on the patient population who would then receive invasive the diagnosis and treatment of gastroparesis. Drossman DA.54:569-573 12. Drossman DA. by a complex of symptom features with physiological support Boston. Drossman DA. Wilson A. Functional gastrointestinal disorders. Predictors of health care 20. There are more review of collective eperience. gastroenterologists. The epidemiology of 22. The need for a new medical model: a challenge for seeking for irritable bowel syndrome and nonulcer dyspepsia: a biomedicine. Dig Dis Sci 1994. 1992 2.130:1552-1556 . Gastroenterology studies like endoscopic retrograde cholangiopancreato. Brain-gut irritable bowel syndrome in North America: a systematic review. AGA technical review of the clinical be treated. we have reduced 8. 2000 b. Drugs 2003. use of esophageal manometry. Vanner S. Fernandes L.97:1910-1915 physiologic relationships. Knight K. Am J Gastroenterol 2001. Gastroenterology 2004. Psychosom Med 1998. placebo for moderate to severe functional bowel disorders. and 14. The functional gastrointestinal disorders and the Rome III process. Fisher RS. Koloski NA. More restrictive criteria for functional disorders of 7. Of course. Presidential address: gastrointestinal illness and functional bowel disorders. Parkman HP.53: 958-964 Rome criteria will enhance the development of our knowledge 16. Shimada Y. WhiteheadWE.124: 303-317 17. factors. Paris.