Inability of the Rome III Criteria to Distinguish Functional Constipation From Constipation-Subtype Irritable Bowel Syndrome

Abstract

Introduction and Aims The Rome III classification system treats functional constipation (FC) and irritable bowel syndrome with constipation (IBS-C) as distinct disorders, but this distinction appears artificial, and the same drugs are used to treat both. This study’s hypothesis is that FC and IBS-C defined by Rome III are not distinct entities. Method 1,100 adults with a primary care visit for constipation and 1,700 age and gender matched controls from a health maintenance organization completed surveys 12 months apart; 66.2% returned the first questionnaire. Rome III criteria identified 231 with FC and 201 with IBS-C. The second survey was completed by 195 of the FC and 141 of the IBS-C cohorts. Both surveys assessed the severity of constipation and IBS, quality of life (QOL), and psychological distress. Results (1) Overlap: If the Rome III requirement that patients meeting criteria for IBS cannot be diagnosed FC is suspended, 89.5% of IBS-C cases meet criteria for FC and 43.8% of FC patients fulfill criteria for IBS-C. (2) No qualitative differences between FC and IBS-C: 44.8% of FC patients report abdominal pain, and paradoxically IBS-C patients have more constipation symptoms than FC. (3) Switching between diagnoses: by 12 months, 1/3 of FC transition to IBS-C and 1/3 of IBS-C change to FC. Conclusions Patients identified by Rome III criteria for FC and IBS-C are not distinct groups. Revisions to the Rome III criteria, possibly including incorporation of physiological tests of transit and pelvic floor function, are needed.

Effective Constipation Treatment Changes More Than Bowel Frequency: A Systematic Review and Meta-Analysis

“…24,25,63,[76][77][78] We recognize that other factors, such as pain frequency or impact on quality of life, were not measured and may define differences in those with constipation compared to IBS-C. While our meta-analysis cannot truly address conceptual issues about disease mechanisms or manifestations, the findings are consistent with prospective cohort studies that show a substantial overlap between constipation and IBS-C. 1,3,4 Prospective studies will have to determine whether and to what degree these diseases are truly distinct or whether they primarily differ based on a potentially shifting focus and emphasis on symptoms associated with constipation.…”

“…1 Although current consensus criteria emphasize the distinction between functional constipation and constipationpredominant irritable bowel syndrome (IBS-C), 2 systematic evaluations have shown a substantial overlap between these disorders. 1,3,4 Thus, it is not surprising that the treatment approaches for either disorders overlap as well. After serious adverse events led to the withdrawal of several drugs targeting functional gastrointestinal diseases, [5][6][7] regulatory agencies in the United States have put forth more stringent criteria for the approval and post-marketing surveillance of novel medications.…”

Pros and Cons While Looking Through an Asian Window on the Rome IV Criteria for Irritable Bowel Syndrome: Pros

“…For example, among patients presenting with chronic constipation, a recent study showed that during follow-up, patients diagnosed as IBS-C may change to functional constipation and vice versa. 19 Also, patients diagnosed with fecal evacuation disorders may fulfill criteria for IBS-C that may improve following correction of the dyssynergia with biofeedback therapy. 20,21 Moreover, there is considerable overlap between functional bowel disorders with gastroduodenal disorders.…”

Assessment of the Asian Neurogastroenterology and Motility Association Chronic Constipation Criteria: An Asian Multicenter Cross-sectional Study

“…However, opposing this theory, a recent study has highlighted the difficulty in distinguishing between CC and IBS-C using Rome III criteria. [15][16][17] Furthermore, it has been suggested that both CC and IBS-C are part of the same condition, 18 and similar therapeutic strategies are often utilized. Ultimately, further study is required to assess the differential diagnoses in those patients who are Rome III-but ANMA+.…”