Bowel Disorders

doi:10.1053/j.gastro.2016.02.031

Gastroenterology

Volume 150, Issue 6, May 2016, Pages 1393-1407.e5

https://doi.org/10.1053/j.gastro.2016.02.031 Get rights and content

Functional bowel disorders are highly prevalent disorders found worldwide. These disorders have the potential to affect all members of society, regardless of age, sex, race, creed, color, or socioeconomic status. Improving our understanding of functional bowel disorders (FBD) is critical, as they impose a negative economic impact to the global health care system in addition to reducing quality of life. Research in the basic and clinical sciences during the past decade has produced new information on the epidemiology, etiology, pathophysiology, diagnosis, and treatment of FBDs. These important findings created a need to revise the Rome III criteria for FBDs, last published in 2006. This article classifies the FBDs into 5 distinct categories: irritable bowel syndrome, functional constipation, functional diarrhea, functional abdominal bloating/distention, and unspecified FBD. Also included in this article is a new sixth category, opioid-induced constipation, which is distinct from the functional bowel disorders (FBDs). Each disorder will first be defined, followed by sections on epidemiology, rationale for changes from prior criteria, clinical evaluation, physiologic features, psychosocial features, and treatment. It is the hope of this committee that this new information will assist both clinicians and researchers in the decade to come.

Section snippets

Definition

IBS is an FBD in which recurrent abdominal pain is associated with defecation or a change in bowel habits. Disordered bowel habits are typically present (ie, constipation, diarrhea, or a mix of constipation and diarrhea), as are symptoms of abdominal bloating/distention. Symptom onset should occur at least 6 months before diagnosis and symptoms should be present during the last 3 months.

Epidemiology

The world-wide prevalence of IBS is 11.2% (95% confidence interval: 9.8%−12.8%) based on a meta-analysis of

Definition

FC is a functional bowel disorder in which symptoms of difficult, infrequent, or incomplete defecation predominate. Patients with FC should not meet IBS criteria, although abdominal pain and/or bloating may be present but are not predominant symptoms. Symptom onset should occur at least 6 months before diagnosis, and symptoms should be present during the last 3 months.

Epidemiology

Few studies have evaluated the incidence and prevalence of FC. Most studies have focused on patients with chronic constipation

Definition

Functional diarrhea (FDr) is an FBD characterized by recurrent passage of loose or watery stools. Patients with FDr should not meet criteria for IBS although abdominal pain and/or bloating may be present, but are not predominant symptoms. Recurrent passage of loose or watery stool onset should have occurred at least 6 months before diagnosis and symptoms should be present during the last 3 months.

Epidemiology

The incidence and prevalence of FDr have not been well investigated. Using a matched, case−control

Definition

Functional abdominal bloating (FAB)/distention (FAD) is characterized by symptoms (subjective) of recurrent abdominal fullness, pressure, or a sensation of trapped gas (FAB), and/or measurable (objective) increase in abdominal girth (FAD). Patients should not meet criteria for other FBDs, although mild abdominal pain and/or minor bowel movement abnormalities may coexist. Symptom onset should be at least 6 months before diagnosis and the predominant symptom (bloating or distention) should be

Definition

In some cases, a patient may not fulfill diagnostic criteria for any of the 4 specific FBDs categories, in which case the patient should be considered to have an unspecified FBD.

C5. Diagnostic Criterion^a for Unspecified Functional Bowel Disorder

Bowel symptoms not attributable to an organic etiology that do not meet criteria for IBS or functional constipation, diarrhea, or abdominal bloating/distention disorders.

^aCriterion fulfilled for the last 3 months with symptom onset at least 6 months

C6. Opioid-Induced Constipation

Opioid-induced bowel disorders refers to a spectrum of disorders that develop secondary to the actions of opioids on the GI tract and the central nervous system. As opiate use has increased, so has the recognition that these agents have a number of adverse effects on the GI tract. It is the opinion of this committee that opioid-induced effects on the GI tract should not be considered a distinct FGID, but rather should be categorized as an opioid-induced adverse effect. There is, however,

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Cited by (1931)

Assessing ‘response’ to the low-FODMAP diet in irritable bowel syndrome: Should we be reporting harder primary endpoints?
2024, Clinical Nutrition
The low-FODMAP diet (LFD) has become almost synonymous with IBS care, yet the challenges associated with this rigorous therapeutic approach are often underacknowledged. Despite positive outcomes in RCTs, comparator groups frequently exhibit substantial response rates, raising questions about the definition of ‘response’. Whilst the assessment of response in drug trials has evolved to utilize the more stringent FDA/EMA primary clinical endpoints, trials of the LFD have not yet followed. The aim of this article is to opine whether the current approach to the measurement of clinical response to the LFD in clinical trials should be reconsidered.
A comprehensive literature review of LFD clinical trials from the past decade was conducted, focusing on recorded response metrics for primary clinical endpoints.
While response definitions vary, the 50-point IBS-SSS delta emerged as the predominant metric. Notably, no trials to date have adopted the more stringent primary clinical endpoints used in drug trials. Other response measures included binary response metrics (such as ‘adequate clinical response’), changes in visual analogue scales or stool form/output, reductions in abdominal pain, as well as changes the magnitude of the IBS-SSS delta. Whether these metrics correspond to a clinically meaningful improvement for the patient is less clear, and as such aligning patient-clinician expectations can be challenging.
A paradigm shift in the conceptualization of ‘response’ coupled with an emphasis on harder clinical endpoints in the context of clinical trials may serve to better justify the trade-off between symptom-improvement and the inherent challenges associated with this burdensome therapeutic approach.
Position paper on transanal irrigation in chronic non-organic constipation
2024, Digestive and Liver Disease
The practice of recto-colonic water irrigation to treat constipation has been used since ancient times with different, uncontrolled, and variably performing methods which have been considered interchangeably all alike. The use of better-performing devices with a standardized methodology is relatively recent, and the term Trans Anal Irrigation (TAI) defines a methodology performed with devices able to control the timing, volume, and pressure of the water introduced into the rectum and colon utilizing a catheter or a cone through the anus. Such practice has been implemented with favorable responses in patients with refractory chronic constipation secondary to neurological diseases.
However, since the role of Trans Anal Irrigation as a therapeutic aid in chronic functional constipation and functional evacuation disorders is not yet fully clarified and standardized, a group of clinical investigators with recognized expertise in these clinical conditions intends to clarify the elements that characterize a TAI procedure that can benefit patients with functional constipation and functional defecation disorders defined according to the lastly updated Rome Diagnostic Criteria. Finally, the paper deals with adherence and practical implementation of TAI.
Lactose-free milk powder can effectively relieve diarrhea symptoms in weaning SD rats and children
2024, Food Science and Human Wellness
Diarrhea has become the leading cause of illness and death among infants and young children in developing countries. Clinically, patients with diarrhea showed damaged intestinal epithelial villi, usually accompanied by lactase deficiency. In this study, we evaluated the therapeutic effects of lactose-free milk powder on rats and children with diarrhea. Antibiotic-associated diarrhea (AAD) model was established by gavage with antibiotic mixture in SD rats, followed by administration of milk powder containing lactose or not. The results showed that lactose-free milk powder ameliorated AAD-related diarrhea symptoms, and accelerated the recovery from diarrhea. And 16S sequencing results indicated lactose-free milk powder contributed to increase the α- and β-diversity of intestinal flora, and restore the intestinal microbiota disorder. In conclusion, our data demonstrate that lactose-free milk powder could alleviate diarrhea by restoring gut microbiota and intestinal barrier function.
Measurement of colonic transit time in patients with refractory chronic constipation referred to a tertiary center
2024, Gastroenterology and Endoscopy
Measurement of colonic transit time (CTT) of different colon segments can help to find the subtype of constipation and the appropriate treatment. This study aimed to estimate the segmental and total CTT in patients with refractory chronic constipation who attended gastrointestinal clinics.
A cross-sectional study was done in patients with refractory chronic constipation according to ROME IV criteria with normal colonoscopy. Patients with underlying diseases, including diabetes, hypoparathyroidism, hypothyroidism, anemia, past intestinal surgery, metabolic disorders, and recent medication use with constipation complications, were excluded. Every patient took a gelatin capsule containing ten 1–3 mm angiographic catheters for six consecutive days. On the seventh day, an upright abdominal x-ray was performed. The remaining markers were counted in three divided colonic segments, and the total CTT using radio-opaque markers was measured subsequently.
40 patients were eventually included in this study. Twenty-eight were female (70%), and 55% of patients had standard body mass index (BMI). The mean age of patients was 43 years with a standard deviation of 18 years, while the mean total CTT was 37.05 h with a standard deviation of 24 h. Additionally, 60% had a normal CTT (≤45 h), and 40% had abnormal and prolonged CTT.
Constipation as a complaint is more common in women than men. Total CTT is slightly higher in men than women, but there is no significant difference. CTT may be normal in patients with refractory constipation despite all investigations. Additionally, there was no correlation between BMI and prolonged total CTT.
Irritable bowel syndrome
2024, Medicine (United Kingdom)
Irritable bowel syndrome (IBS) is a disorder of brain–gut interaction (formerly known as a functional gastrointestinal disorder) typically characterized by at least weekly abdominal pain associated with a change in frequency and form of the stool. IBS is common, with a population prevalence of around 5%. It is associated with a marked reduction in quality of life and significant healthcare expenditure. Its pathophysiology remains incompletely understood. IBS is subclassified according to the predominant bowel habit. Treatments are directed towards improving the predominant symptoms and include dietary/lifestyle modifications, medication and psychological interventions.
Quality of Life and Bidirectional Gut-Brain Interactions in Irritable Bowel Syndrome From Adolescence to Adulthood
2024, Clinical Gastroenterology and Hepatology
Reports on cross-sectional and longitudinal associations between health-related quality of life (HRQoL), psychological distress, and irritable bowel syndrome (IBS) in the adolescent and young adult general population are few. We aimed to describe cross-sectional associations between HRQoL and IBS in adolescence and young adulthood, and examine bidirectional gut-brain interactions in the transition from childhood to adulthood.
We included 3391 subjects from a prospective birth cohort study, with data on IBS at 16 years of age and 24 years of age. IBS was assessed using the pediatric Rome III (16 years of age) and the adult Rome IV (24 years of age) diagnostic questionnaires. HRQoL and psychological distress were assessed through EQ-5D. Sex-adjusted logistic regression models were used to examine associations between overall HRQoL/psychological distress at 16 years of age and new-onset IBS at 24 years of age (brain-gut) and between IBS at 16 years of age and new-onset psychological distress at 24 years of age (gut-brain).
In subjects with vs without IBS at 16 and 24 years of age, overall HRQoL (EQ visual analog scale, EQ-5D index value) was lower, and it was more common reporting problems in 4 of 5 EQ-5D dimensions (all P < .05). EQ-5D index value at 16 years of age was inversely associated (odds ratio [OR], 0.1, 95% confidence interval [CI], 0.01–0.6), and psychological distress at 16 years of age was positively associated (OR, 1.6; 95% CI, 1.2–2.3), with new-onset IBS at 24 years of age. Having any abdominal pain–related disorder of gut-brain interaction at 16 years of age was associated with new-onset psychological distress at 24 years of age (OR, 1.7; 95% CI, 1.2–2.5).
Adolescents and young adults with IBS in the general population have impaired HRQoL. Bidirectional gut-brain interactions are relevant for symptom generation in abdominal pain–related disorders of gut-brain interaction, and for HRQoL impairment and psychological distress in the transition from childhood to adulthood.

View all citing articles on Scopus

: Conflicts of interest The authors disclose no conflicts.

View full text

Section II: FGIDs: Diagnostic GroupsBowelBowel Disorders

Section snippets

Definition

Epidemiology

Definition

Epidemiology

Definition

Epidemiology

Definition

Definition

C6. Opioid-Induced Constipation

J Psychosom Res

Gastroenterology

Psychosomatics

Gastroenterology

Gastroenterology

Global prevalence of and risk factors for irritable bowel syndrome: a meta-analysis

Clin Gastroenterol Hepatol

Irritable bowel syndrome: a 10-yr natural history of symptoms and factors that influence consultation behavior

Am J Gastroenterol

Natural history of functional gastrointestinal disorders: a 12-year longitudinal population-based study

Gastroenterology

Measuring symptoms in the irritable bowel syndrome: development of a framework for clinical trials

Aliment Pharmacol Ther

Abdominal pain versus abdominal discomfort: implications for diagnostic assessment of irritable bowel syndrome (IBS)

United Eur Gastroenterol J

Diagnostic criteria in IBS: useful or not?

Neurogastroenterol Motil

A positive diagnostic strategy is noninferior to a strategy of exclusion for patients with irritable bowel syndrome

Clin Gastroenterol Hepatol

New clinical method for distinguishing D-IBS from other gastrointestinal conditions causing diarrhea: the LA/IBS diagnostic strategy

Dig Dis Sci

Episodic nature of symptoms in irritable bowel syndrome

Am J Gastroenterol

Stool form scale as a useful guide to intestinal transit time

Scand J Gastroenterol

Short-term stability of subtypes in the irritable bowel syndrome: prospective evaluation using the Rome III classification

Aliment Pharmacol Ther

Comorbidity of irritable bowel syndrome in general practice: a striking feature with clinical implications

Aliment Pharmacol Ther

Comorbidity in irritable bowel syndrome

Am J Gastroenterol

Predictors of patient-assessed illness severity in irritable bowel syndrome

Am J Gastroenterol

Validation of the Rome III criteria for the diagnosis of irritable bowel syndrome in secondary care

Gastroenterology

Will the history and physical examination help establish that irritable bowel syndrome is causing this patient's lower gastrointestinal tract symptoms?

JAMA

Prevalence of organic disease at colonoscopy in patients with symptoms compatible with irritable bowel syndrome: cross-sectional survey

Scand J Gastroenterol

Meta-analysis of the utility of common serum and fecal biomarkers in adults with IBS

Gastroenterology

Faecal calprotectin testing for differentiating amongst inflammatory and non-inflammatory bowel diseases: systematic review and economic evaluation

Health Technol Assess

Section II: FGIDs: Diagnostic Groups
Bowel
Bowel Disorders