Rome process
Encyclopedia
The "Rome process" is an international effort to create scientific data to help in the diagnosis
and treatment of functional gastrointestinal disorders, (FGIDs), such as irritable bowel syndrome
, functional dyspepsia and rumination syndrome. The Rome Diagnostic Criteria are set forth by the Rome Foundation, a not for profit 501(c)(3) organization, under the professional management of Degnon Associates based in McLean, Virginia.
patients at Oxford
, England. Later on, the "Manning Criteria
" for irritable bowel syndrome were derived from a paper published in 1978 by Manning and colleagues. This seminal classification started a new era and from then on, scientific work on functional gastrointestinal disorders proceeded with increased enthusiasm.
The Rome criteria have been evolving from the first set of criteria issued in 1989 (The Rome Guidelines for IBS) through the Rome Classification System for FGIDs (1990), or Rome-1, the Rome I Criteria for IBS (1992) and the FGIDs (1994), the Rome II Criteria for IBS (1999) and the FGIDs (1999) to the recent Rome III Criteria (2006). "Rome II" and "Rome III" incorporated pediatric criteria to the consensus.
(or Delphi Technique). The effort is organised by the Rome Coordinating Committee. This process typically takes many months of work by investigators, organized into committees. The committees work by mail and telephone conferences until the final, defining meeting, which takes place in Rome
, Italy
. The Rome III effort encompassed 87 participants from 18 countries in 14 committees. Members were added from countries outside the more industrialized Western nations; this time there were members from China
, Brazil
, Chile
, Venezuela
, Hungary
, and Romania
. Additional working teams were created to work on issues including: gender
, society
, patient
, and social
issues; and pharmacology
and pharmacokinetics
. Two committees (neonate/toddler
and child
/adolescent), rather than one, served the pediatrics
FGIDs.
s (FGIDs) are classified into six major domains for adults:
The functional bowel disorders (category C) include: irritable bowel syndrome (C1); functional bloating
(C2); functional constipation
(C3); functional diarrhea
(C4)
Irritable bowel syndrome (C1) is more specifically defined as pain
associated with change in bowel habit, which is different from functional diarrhea.
According to the Rome II committees and the Functional Brain Gut Research Group,
IBS can be diagnosed based on at least 12 weeks, which need not be consecutive, of the preceding 12 months there was abdominal discomfort or pain that had two out of three of these features:
Symptoms that cumulatively support the diagnosis of IBS:
Supportive symptoms of IBS:
Diarrhea-predominant: At least 1 of B, D, F and none of A, C, E; or at least 2 of B, D, F and one of A or E.
Constipation-predominant: At least 1 of A, C, E and none of B, D, F; or at least 2 of A, C, E and one of B, D, F.
Red flag symptoms which are not typical of IBS:
An update to these criteria was issued at the Rome III conference and published in May 2006. The validity of subtypes is called into question:
In addition to meeting these positive criteria, patients have initial laboratory testing with a complete blood count, basic chemistry panel, and an erythrocyte sedimentation rate. Diagnostic accuracy for IBS is over 95% when Rome II criteria are met, history and physical exam do not suggest any other cause, and initial laboratory testing is negative.
In the past it was thought that the diagnosis of IBS relied on a diagnosis of exclusion; that is, if one cannot find a cause then IBS is the diagnosis. Currently the diagnosis of IBS relies on meeting Rome II inclusion criteria (updated by Rome III criteria) and excluding other illnesses based on history, physical exam, and laboratory testing. Although the Rome II and III criteria were not designed to be management guidelines, they are currently a "gold standard" for the diagnosis of IBS. Unfortunately, an IBS diagnosis in an adult patient is still only useful as a tool to rule out more serious problems unless further investigation is employed to discern an addressable condition.
Diagnosis
Diagnosis is the identification of the nature and cause of anything. Diagnosis is used in many different disciplines with variations in the use of logics, analytics, and experience to determine the cause and effect relationships...
and treatment of functional gastrointestinal disorders, (FGIDs), such as irritable bowel syndrome
Irritable bowel syndrome
Irritable bowel syndrome is a diagnosis of exclusion. It is a functional bowel disorder characterized by chronic abdominal pain, discomfort, bloating, and alteration of bowel habits in the absence of any detectable organic cause. In some cases, the symptoms are relieved by bowel movements...
, functional dyspepsia and rumination syndrome. The Rome Diagnostic Criteria are set forth by the Rome Foundation, a not for profit 501(c)(3) organization, under the professional management of Degnon Associates based in McLean, Virginia.
History
There were systematic approaches that attempted to classify the then hazy area of functional gastrointestinal disorders as early as 1962 when Chaudhary and Truelove published a retrospective review of IBSIrritable bowel syndrome
Irritable bowel syndrome is a diagnosis of exclusion. It is a functional bowel disorder characterized by chronic abdominal pain, discomfort, bloating, and alteration of bowel habits in the absence of any detectable organic cause. In some cases, the symptoms are relieved by bowel movements...
patients at Oxford
Oxford
The city of Oxford is the county town of Oxfordshire, England. The city, made prominent by its medieval university, has a population of just under 165,000, with 153,900 living within the district boundary. It lies about 50 miles north-west of London. The rivers Cherwell and Thames run through...
, England. Later on, the "Manning Criteria
Manning Criteria
The Manning Criteria is a diagnostic algorithm used in the diagnosis of Irritable Bowel Syndrome. The criteria consists of a list of questions the physician can ask the patient...
" for irritable bowel syndrome were derived from a paper published in 1978 by Manning and colleagues. This seminal classification started a new era and from then on, scientific work on functional gastrointestinal disorders proceeded with increased enthusiasm.
The Rome criteria have been evolving from the first set of criteria issued in 1989 (The Rome Guidelines for IBS) through the Rome Classification System for FGIDs (1990), or Rome-1, the Rome I Criteria for IBS (1992) and the FGIDs (1994), the Rome II Criteria for IBS (1999) and the FGIDs (1999) to the recent Rome III Criteria (2006). "Rome II" and "Rome III" incorporated pediatric criteria to the consensus.
Process
The Rome criteria are achieved and finally issued through a consensual process, using the Delphi methodDelphi method
The Delphi method is a structured communication technique, originally developed as a systematic, interactive forecasting method which relies on a panel of experts.In the standard version, the experts answer questionnaires in two or more rounds...
(or Delphi Technique). The effort is organised by the Rome Coordinating Committee. This process typically takes many months of work by investigators, organized into committees. The committees work by mail and telephone conferences until the final, defining meeting, which takes place in Rome
Rome
Rome is the capital of Italy and the country's largest and most populated city and comune, with over 2.7 million residents in . The city is located in the central-western portion of the Italian Peninsula, on the Tiber River within the Lazio region of Italy.Rome's history spans two and a half...
, Italy
Italy
Italy , officially the Italian Republic languages]] under the European Charter for Regional or Minority Languages. In each of these, Italy's official name is as follows:;;;;;;;;), is a unitary parliamentary republic in South-Central Europe. To the north it borders France, Switzerland, Austria and...
. The Rome III effort encompassed 87 participants from 18 countries in 14 committees. Members were added from countries outside the more industrialized Western nations; this time there were members from China
China
Chinese civilization may refer to:* China for more general discussion of the country.* Chinese culture* Greater China, the transnational community of ethnic Chinese.* History of China* Sinosphere, the area historically affected by Chinese culture...
, Brazil
Brazil
Brazil , officially the Federative Republic of Brazil , is the largest country in South America. It is the world's fifth largest country, both by geographical area and by population with over 192 million people...
, Chile
Chile
Chile ,officially the Republic of Chile , is a country in South America occupying a long, narrow coastal strip between the Andes mountains to the east and the Pacific Ocean to the west. It borders Peru to the north, Bolivia to the northeast, Argentina to the east, and the Drake Passage in the far...
, Venezuela
Venezuela
Venezuela , officially called the Bolivarian Republic of Venezuela , is a tropical country on the northern coast of South America. It borders Colombia to the west, Guyana to the east, and Brazil to the south...
, Hungary
Hungary
Hungary , officially the Republic of Hungary , is a landlocked country in Central Europe. It is situated in the Carpathian Basin and is bordered by Slovakia to the north, Ukraine and Romania to the east, Serbia and Croatia to the south, Slovenia to the southwest and Austria to the west. The...
, and Romania
Romania
Romania is a country located at the crossroads of Central and Southeastern Europe, on the Lower Danube, within and outside the Carpathian arch, bordering on the Black Sea...
. Additional working teams were created to work on issues including: gender
Gender
Gender is a range of characteristics used to distinguish between males and females, particularly in the cases of men and women and the masculine and feminine attributes assigned to them. Depending on the context, the discriminating characteristics vary from sex to social role to gender identity...
, society
Society
A society, or a human society, is a group of people related to each other through persistent relations, or a large social grouping sharing the same geographical or virtual territory, subject to the same political authority and dominant cultural expectations...
, patient
Patient
A patient is any recipient of healthcare services. The patient is most often ill or injured and in need of treatment by a physician, advanced practice registered nurse, veterinarian, or other health care provider....
, and social
Social
The term social refers to a characteristic of living organisms...
issues; and pharmacology
Pharmacology
Pharmacology is the branch of medicine and biology concerned with the study of drug action. More specifically, it is the study of the interactions that occur between a living organism and chemicals that affect normal or abnormal biochemical function...
and pharmacokinetics
Pharmacokinetics
Pharmacokinetics, sometimes abbreviated as PK, is a branch of pharmacology dedicated to the determination of the fate of substances administered externally to a living organism...
. Two committees (neonate/toddler
Toddler
A toddler is a young child, usually defined as being between the ages of one and three. Registered nurse, midwife and author, Robin Barker, states 'Any time from eight months onwards your baby will begin to realise he is a separate person from you...
and child
Child
Biologically, a child is generally a human between the stages of birth and puberty. Some vernacular definitions of a child include the fetus, as being an unborn child. The legal definition of "child" generally refers to a minor, otherwise known as a person younger than the age of majority...
/adolescent), rather than one, served the pediatrics
Pediatrics
Pediatrics or paediatrics is the branch of medicine that deals with the medical care of infants, children, and adolescents. A medical practitioner who specializes in this area is known as a pediatrician or paediatrician...
FGIDs.
Adult patients
In the Rome III classification, the functional gastrointestinal disorderFunctional gastrointestinal disorder
Functional gastrointestinal disorder include a number of separate idiopathic disorders which affect different part of the gastrointestinal tract.-Classification:*Functional esophageal disorders**Functional heartburn...
s (FGIDs) are classified into six major domains for adults:
- EsophagealEsophagusThe esophagus is an organ in vertebrates which consists of a muscular tube through which food passes from the pharynx to the stomach. During swallowing, food passes from the mouth through the pharynx into the esophagus and travels via peristalsis to the stomach...
(category A) - Gastroduodenal (category B)
- Bowel (category C)
- Functional Abdominal Pain SyndromeChronic functional abdominal painChronic functional abdominal pain is the ongoing presence of abdominal pain for which there is no known medical explanation. It is quite similar to, but less common than, irritable bowel syndrome , and many of the same treatments for IBS can also be of benefit to those with CFAP...
(category D) - Biliary (category E)
- AnorectalAnorectalNot to be confused with anorexia.Anorectal anomalies are medical problems affecting the structure of the anus and rectum. A person with an anorectal problem would have some sort of deformative feature of the anus or rectum, collectively known as an anorectal malformation.Examples of anorectal...
(category F)
The functional bowel disorders (category C) include: irritable bowel syndrome (C1); functional bloating
Bloating
Bloating is any abnormal general swelling, or increase in diameter of the abdominal area. As a symptom, the patient feels a full and tight abdomen, which may cause abdominal pain sometimes accompanied by increased borborygmus or more seriously the total lack of borborygmus.-Symptoms:The most common...
(C2); functional constipation
Constipation
Constipation refers to bowel movements that are infrequent or hard to pass. Constipation is a common cause of painful defecation...
(C3); functional diarrhea
Diarrhea
Diarrhea , also spelled diarrhoea, is the condition of having three or more loose or liquid bowel movements per day. It is a common cause of death in developing countries and the second most common cause of infant deaths worldwide. The loss of fluids through diarrhea can cause dehydration and...
(C4)
Irritable bowel syndrome (C1) is more specifically defined as pain
Pain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...
associated with change in bowel habit, which is different from functional diarrhea.
Pediatric patients
The pediatric domains are classified first by age range and then by symptom pattern or area of symptom. Each domain contains several disorders, each with relatively specific clinical features.- Neonate/ToddlerToddlerA toddler is a young child, usually defined as being between the ages of one and three. Registered nurse, midwife and author, Robin Barker, states 'Any time from eight months onwards your baby will begin to realise he is a separate person from you...
(category G)- G1. Infant regurgitationRegurgitation (digestion)Regurgitation is the expulsion of material from the mouth, pharynx, or esophagus, usually characterized by the presence of undigested food or blood.Regurgitation is used by a number of species to feed their young...
- G2. Infant ruminationRuminationThe term rumination , meaning "to chew the cud," is used in several contexts:-Digestive rumination:* In animals, rumination is a part of normal digestion, in which the animal brings up swallowed food , chews it, and swallows it...
syndrome - G3. Cyclic vomitingVomitingVomiting is the forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose...
syndrome - G4. Infant colicColicColic is a form of pain which starts and stops abruptly. Types include:*Baby colic, a condition, usually in infants, characterized by incessant crying*Renal colic, a pain in the flank, characteristic of kidney stones...
- G5. Functional diarrheaDiarrheaDiarrhea , also spelled diarrhoea, is the condition of having three or more loose or liquid bowel movements per day. It is a common cause of death in developing countries and the second most common cause of infant deaths worldwide. The loss of fluids through diarrhea can cause dehydration and...
- G6. Infant dyschezia
- G7. Functional constipationConstipationConstipation refers to bowel movements that are infrequent or hard to pass. Constipation is a common cause of painful defecation...
- G1. Infant regurgitation
- ChildChildBiologically, a child is generally a human between the stages of birth and puberty. Some vernacular definitions of a child include the fetus, as being an unborn child. The legal definition of "child" generally refers to a minor, otherwise known as a person younger than the age of majority...
/Adolescent (category H)- H1. Vomiting and aerophagiaAerophagiaAerophagia is a condition that occurs when a person swallows too much air, which goes to the stomach. It causes abdominal bloating and frequent belching and may cause pain.-Causes:...
: H1a. Adolescent rumination syndrome; H1b. Cyclic vomiting syndrome; H1c. Aerophagia - H2. Abdominal pain–related FGIDs: H2a. Functional dyspepsiaDyspepsiaDyspepsia , also known as upset stomach or indigestion, refers to a condition of impaired digestion. It is a medical condition characterized by chronic or recurrent pain in the upper abdomen, upper abdominal fullness and feeling full earlier than expected when eating...
; H2b. Irritable bowel syndromeIrritable bowel syndromeIrritable bowel syndrome is a diagnosis of exclusion. It is a functional bowel disorder characterized by chronic abdominal pain, discomfort, bloating, and alteration of bowel habits in the absence of any detectable organic cause. In some cases, the symptoms are relieved by bowel movements...
; H2c. Abdominal migraineMigraineMigraine is a chronic neurological disorder characterized by moderate to severe headaches, and nausea...
; H2d. Childhood functional abdominal pain - H3. Constipation and incontinenceFecal incontinenceFecal incontinence is the loss of regular control of the bowels. Involuntary excretion and leaking are common occurrences for those affected. Subjects relating to defecation are often socially unacceptable, thus those affected may be beset by feelings of shame and humiliation...
: H3a. Functional constipation; H3b. Nonretentive fecal incontinenceFecal incontinenceFecal incontinence is the loss of regular control of the bowels. Involuntary excretion and leaking are common occurrences for those affected. Subjects relating to defecation are often socially unacceptable, thus those affected may be beset by feelings of shame and humiliation...
- H1. Vomiting and aerophagia
Rome Process for Diagnosing IBS
Physicians rely on a variety of procedures and laboratory tests to confirm a diagnosis. The cardinal requirement for the diagnosis of IBS is abdominal pain. The Rome II criteria are used to diagnose IBS after a careful examination of the patient's medical history and physical abdominal examination which looks for any 'red flag' symptoms. More recently, the Rome III criteria, incorporating some changes over the previous set of criteria, have been issued. The Rome II and III efforts have integrated pediatric components in their set of criteria.According to the Rome II committees and the Functional Brain Gut Research Group,
IBS can be diagnosed based on at least 12 weeks, which need not be consecutive, of the preceding 12 months there was abdominal discomfort or pain that had two out of three of these features:
- Relieved with defecation; and/or
- Onset associated with a change in frequency of stool; and/or
- Onset associated with a change in form (appearance) of stool.
Symptoms that cumulatively support the diagnosis of IBS:
- Abnormal stool frequency (for research purposes, "abnormal" may be defined as greater than three bowel movements per day and fewer than three bowel movements per week);
- Abnormal stool form (lumpy/hard or loose/watery stool);
- Abnormal stool passage (straining, urgency, or feeling of incomplete evacuation);
- Bloating or feeling of abdominal distention.
Supportive symptoms of IBS:
- A) Fewer than three bowel movements a week
- B) More than three bowel movements a day
- C) Hard or lumpy stools
- D) Loose (mushy) or watery stools
- E) Straining during a bowel movement
- F) Urgency (having to rush to have a bowel movement)
- G) Feeling of incomplete bowel movement
- H) Passing mucus (white material) during a bowel movement
- I) Abdominal fullness, bloating, or swelling
Diarrhea-predominant: At least 1 of B, D, F and none of A, C, E; or at least 2 of B, D, F and one of A or E.
Constipation-predominant: At least 1 of A, C, E and none of B, D, F; or at least 2 of A, C, E and one of B, D, F.
Red flag symptoms which are not typical of IBS:
- Pain that awakens/interferes with sleep
- Diarrhea that awakens/interferes with sleep
- Blood in the stool (visible or occult)
- Weight loss
- Fever
- Abnormal physical examination
An update to these criteria was issued at the Rome III conference and published in May 2006. The validity of subtypes is called into question:
- The validity and stability of such subtypes over time is unknown and should be the subject of future research.
- Because of the characteristic symptom instability, we prefer the terms IBS with constipation and IBS with diarrhea instead of constipation- and diarrhea-predominant IBS. In this categorical system, many people whose features place them close to a subtype boundary change pattern without a major change in pathophysiology. Moreover, the heterogeneity and variable natural history of IBS significantly limit clinical trials of motility-active drugs and drug therapy in practice.
In addition to meeting these positive criteria, patients have initial laboratory testing with a complete blood count, basic chemistry panel, and an erythrocyte sedimentation rate. Diagnostic accuracy for IBS is over 95% when Rome II criteria are met, history and physical exam do not suggest any other cause, and initial laboratory testing is negative.
In the past it was thought that the diagnosis of IBS relied on a diagnosis of exclusion; that is, if one cannot find a cause then IBS is the diagnosis. Currently the diagnosis of IBS relies on meeting Rome II inclusion criteria (updated by Rome III criteria) and excluding other illnesses based on history, physical exam, and laboratory testing. Although the Rome II and III criteria were not designed to be management guidelines, they are currently a "gold standard" for the diagnosis of IBS. Unfortunately, an IBS diagnosis in an adult patient is still only useful as a tool to rule out more serious problems unless further investigation is employed to discern an addressable condition.