Carolina Bolino

Validation of the Rome III Criteria for the Diagnosis of Irritable Bowel Syndrome in Secondary Care

BACKGROUND & AIMS There are few validation studies of existing diagnostic criteria for irritable bowel syndrome (IBS). We conducted a validation study of the Rome and Manning criteria in secondary care. METHODS We collected complete symptom, colonoscopy, and histology data from 1848 consecutive adult patients with gastrointestinal symptoms at 2 hospitals in Hamilton, Ontario; the subjects then underwent colonoscopy. Assessors were blinded to symptom status. Individuals with normal colonoscopy and histopathology results, and no evidence of celiac disease, were classified as having no organic gastrointestinal disease. The reference standard used to define the presence of true IBS was lower abdominal pain or discomfort in association with a change in bowel habit and no organic gastrointestinal disease. Sensitivity, specificity, and positive and negative likelihood ratios, with 95% confidence intervals, were calculated for each diagnostic criteria. RESULTS In identifying patients with IBS, sensitivities of the criteria ranged from 61.9% (Manning) to 95.8% (Rome I), and specificities from 70.6% (Rome I) to 81.8% (Manning). Positive likelihood ratios ranged from 3.19 (Rome II) to 3.39 (Manning), and negative likelihood ratios from 0.06 (Rome I) to 0.47 (Manning). The level of agreement between diagnostic criteria was greatest for Rome I and Rome II (κ = 0.95), and lowest for Manning and Rome III (κ = 0.59). CONCLUSIONS Existing diagnostic criteria perform modestly in distinguishing IBS from organic disease. There appears to be little difference in terms of accuracy. More accurate ways of diagnosing IBS, avoiding the need for investigation, are required.

Characteristics of functional bowel disorder patients: a cross-sectional survey using the Rome III criteria

There is some evidence that, despite attempts to classify them separately, functional bowel disorders are not distinct entities and that such divisions are artificial.

The Rome III Criteria for the Diagnosis of Functional Dyspepsia in Secondary Care Are Not Superior to Previous Definitions

BACKGROUND & AIMS Although the Rome III criteria for functional dyspepsia were defined 7 years ago, they have yet to be validated in a rigorous study. We addressed this issue in a secondary-care population. METHODS We analyzed complete symptom, upper gastrointestinal (GI) endoscopy, and histology data from 1452 consecutive adult patients with GI symptoms at 2 hospitals in Hamilton, Ontario, Canada. Assessors were blinded to symptom status. Individuals with normal upper GI endoscopy and histopathology findings from analyses of biopsy specimens were classified as having no organic GI disease. The reference standard used to define the presence of true functional dyspepsia was epigastric pain, early satiety or postprandial fullness, and no organic GI disease. Sensitivity, specificity, and positive and negative likelihood ratios (LRs), with 95% confidence intervals (CIs), were calculated. RESULTS Of the 1452 patients, 722 (49.7%) met the Rome III criteria for functional dyspepsia. Endoscopy showed organic GI disease in 170 patients (23.5%) who met the Rome III criteria. The Rome III criteria identified patients with functional dyspepsia with 60.7% sensitivity, 68.7% specificity, a positive LR of 1.94 (95% CI, 1.69-2.22), and a negative LR of 0.57 (95% CI, 0.52-0.63). In contrast, the Rome II criteria identified patients with functional dyspepsia with 71.4% sensitivity, 55.6% specificity, a positive LR of 1.61 (95% CI, 1.45-1.78), and a negative LR of 0.51 (95% CI, 0.45-0.58). The area under a receiver operating characteristics curves did not differ significantly for any of the diagnostic criteria for functional dyspepsia. CONCLUSIONS In a validation study of 1452 patients with GI symptoms, the Rome III criteria performed only modestly in identifying those with functional dyspepsia, and were not significantly superior to previous definitions.

Irritable bowel syndrome is significantly associated with somatisation in 840 patients, which may drive bloating

Psychological factors may influence persistence and perceived severity of symptoms in irritable bowel syndrome (IBS). Literature suggests that somatisation is associated with IBS. However, the relationship between IBS subtype, symptoms of IBS and somatisation is unclear.

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

Abstract Objective. Guidelines for the management of irritable bowel syndrome (IBS) encourage a positive diagnosis, but some evidence suggests organic disease may be missed unless investigations are performed. We examined yield of colonoscopy in a cohort of secondary care patients meeting criteria for IBS. Materials and methods. Demographic data, symptoms and findings at colonoscopy were recorded prospectively in consecutive, unselected adults with gastrointestinal (GI) symptoms compatible with IBS according to the Rome III criteria. Prevalence of organic GI disease was compared between those meeting criteria for IBS, according to the presence or absence of co-existent alarm features, and by IBS subtype. Results. A total of 559 patients met Rome III criteria for IBS, of whom 423 reported ≥1 alarm feature and 136 none. There was a significantly higher prevalence of organic GI disease among those reporting alarm features (117 [27.7%]), compared with those without (21 [15.4%]) (p = 0.002). In the latter group of 136 patients, Crohn’s disease was the commonest finding (10 [7.4%] subjects), followed by coeliac disease (4 [2.9%] subjects), and microscopic colitis (3 [2.2%] subjects). Regardless of presence or absence of alarm features, patients with constipation-predominant IBS were less likely to exhibit organic GI disease than those with diarrhea-predominant or mixed IBS (12.7% vs. 32.1% and 23.8%, p = 0.006). Conclusions. One in six patients with symptoms compatible with IBS without alarm features in this selected group exhibited organic GI disease following investigation. Assessment of alarm features in a comprehensive history is vital to reduce diagnostic uncertainty that can surround IBS.

Pathogenic factors involved in the development of irritable bowel syndrome: focus on a microbial role.

Irritable bowel syndrome (IBS) is a symptom complex characterized by recurrent abdominal pain or discomfort, and accompanied by abnormal bowel habits, in the absence of any discernible organic abnormality. Its origin remains unclear, partly because multiple pathophysiologic mechanisms are likely to be involved. A significant proportion of patients develop IBS symptoms after an episode of gastrointestinal infection. In addition to gastrointestinal pathogens, recent evidence suggests that patients with IBS have abnormal composition and higher temporal instability of their intestinal microbiota. Because the intestinal microbiota is an important determinant of normal gut function and immunity, this instability may constitute an additional mechanism that leads to symptom generation and IBS. More importantly, a role for altered microbiota composition in IBS raises the possibility of therapeutic interventions through selective antibiotic or probiotic administration. The new concept of functional bowel diseases incorporates the bidirectional communication between the gut and the central nervous system (gut-brain axis), which may explain the multiple facets of IBS by linking emotional and cognitive centers of the brain with peripheral functioning of the gastrointestinal tract and vice versa.

No increase in prevalence of somatization in functional vs organic dyspepsia: a cross-sectional survey.

Psychological factors are associated with functional gastrointestinal (GI) disorders. Literature suggests that somatization is associated with functional dyspepsia (FD). However, the relationship between organic dyspepsia (OD), FD, and FD subtypes and somatization is poorly described. We aimed to examine this issue in a cross‐sectional study of secondary care patients.

Lack of Utility of Symptoms and Signs at First Presentation as Predictors of Inflammatory Bowel Disease in Secondary Care

OBJECTIVES:There are few data concerning the utility of symptoms and signs at first presentation in predicting a diagnosis of ulcerative colitis (UC) or Crohn’s disease (CD). We conducted a study to examine this issue in secondary care.METHODS:We collected complete symptom, colonoscopy, and histology data prospectively from 1,981 consecutive adult patients with lower gastrointestinal symptoms at two hospitals in Hamilton, Ontario. Assessors were blinded to symptom status. The reference standard used to define the presence of UC or CD was according to accepted histological criteria. Patients without UC or CD served as controls. Sensitivity, specificity, and positive and negative likelihood ratios (LRs) were calculated for individual items from the clinical history, as well as combinations of these.RESULTS:In identifying 302 patients with inflammatory bowel diseases (IBD), positive LRs for individual items ranged from 1.18 (incomplete emptying) to 2.30 (passage of stools more than four times per day at least most of the time) and negative LRs from 0.70 (bloody stools) to 0.96 (incomplete emptying). Combinations of items had a high specificity, but at the expense of sensitivity. Items that were independent predictors of IBD after logistic regression analysis were family history of IBD, younger age, passage of stools more than four times per day ≥75% of the time, urgency most of the time, and anemia.CONCLUSIONS:Individual items from the clinical history are not helpful in predicting a diagnosis of UC or CD. However, this may be because some items lacked sufficient detail. Combinations of symptoms and computer models had a high specificity, but overall were only modestly useful diagnostically. Future studies should evaluate biological markers in combination with symptoms to improve accuracy.

Poor predictive value of lower gastrointestinal alarm features in the diagnosis of colorectal cancer in 1981 patients in secondary care

Clinicians are advised to refer patients with lower gastrointestinal (GI) alarm features for urgent colonoscopy to exclude colorectal cancer (CRC). However, the utility of alarm features is debated.

Letter: NICE referral criteria for lower gastrointestinal alarm features - not ideal but not poor either. Authors' reply

*Academic Unit of Primary Care, University of Leeds, Leeds, UK. Gastroenterology Division, Health Sciences Center, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada. Gastroenterology Department, St. Joseph’s Healthcare, Hamilton, ON, Canada. Leeds Gastroenterology Institute, St. James’s University Hospital, Leeds, UK. Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK. E-mail: alexf12399@yahoo.com