Gut 1999;45(Suppl II):II43–II47 II43 Functional bowel disorders and functional abdominal pain

W G Thompson, G F Longstreth, D A Drossman, K W Heaton, E J Irvine, S A Müller-Lissner

Abstract Table 1 Functional gastrointestinal disorders The Rome diagnostic criteria for the A. Esophageal disorders functional bowel disorders and functional A1. Globus abdominal pain are used widely in re- A2. Rumination syndrome search and practice. A committee consen- A3. Functional chest pain of presumed esophageal origin A4. Functional heartburn sus approach, including criticism from A5. Functional dysphagia multinational expert reviewers, was used A6. Unspecified functional esophageal disorder to revise the diagnostic criteria and B. Gastroduodenal disorders Chair, Committee on B1. Functional dyspepsia Functional Bowel update diagnosis and treatment recom- B1a. Ulcer-like dyspepsia Disorders and mendations, based on research results. B1b. Dysmotility-like dyspepsia B1c. Unspecified (non-specific) dyspepsia Functional Abdominal The terminology was clarified and the B2. Aerophagia Pain, Multinational diagnostic criteria and management rec- B3. Functional vomiting Working Teams to ommendations were revised. A functional C. Bowel disorders Develop Diagnostic C1. Irritable bowel syndrome Criteria for Functional bowel disorder (FBD) is diagnosed by C2. Functional abdominal bloating Gastrointestinal characteristic symptoms for at least 12 C3. Functional constipation C4. Functional diarrhea Disorders (Rome II), weeks during the preceding 12 months in C5. Unspecified functional bowel disorder Emeritus Professor of the absence of a structural or biochemical D. Functional abdominal pain Medicine, explanation. The irritable bowel syn- D1. Functional abdominal pain syndrome University of Ottawa, drome, functional abdominal bloating, D2. Unspecified functional abdominal pain Canada E. Biliary disorders W G Thompson functional constipation, and functional E1. Gall bladder dysfunction diarrhea are distinguished by symptom- E2. Sphincter of Oddi dysfunction F. Anorectal disorders Co-Chair, Committee based diagnostic criteria. Unspecified F1. Functional fecal incontinence on Functional Bowel FBD lacks criteria for the other FBDs. F2. Functional anorectal pain Disorders and Diagnostic testing is individualized, de- F2a. Levator ani syndrome Functional Abdominal F2b. Proctalgia fugax Pain, Multinational pending on patient age, primary symptom F3. Pelvic floor dyssynergia characteristics, and other clinical and G. Functional pediatric disorders Working Teams to G1. Vomiting Develop Diagnostic laboratory features. Functional abdomi- G1a. Infant regurgitation Criteria for Functional nal pain (FAP) is defined as either the G1b. Infant rumination syndrome Gastrointestinal FAP syndrome, which requires at least six G1c. Cyclic vomiting syndrome Disorders (Rome II), G2. Abdominal pain Kaiser Permanente, months of pain with poor relation to gut G2a. Functional dyspepsia function and loss of daily activities, or G2b. Irritable bowel syndrome San Diego, CA, USA G2c. Functional abdominal pain G F Longstreth unspecified FAP, which lacks criteria for G2d. Abdominal migraine the FAP syndrome. An organic cause for G2e. Aerophagia Division of Digestive the pain must be excluded, but aspects of G3. Functional diarrhea Diseases, the patient’s pain behavior are of primary G4. Disorders of defecation University of North G4a. Infant dyschezia Carolina, Chapel Hill, importance. Treatment of the FBDs relies G4b. Functional constipation upon confident diagnosis, explanation, G4c. Functional fecal retention NC, USA G4d. Non-retentive fecal soiling D A Drossman and reassurance. Diet alteration, drug treatment, and psychotherapy may be Department of beneficial, depending on the symptoms comment further on diagnosis, and summarize Medicine, and psychological features. University of Bristol, treatment recommendations. ( 1999; (Suppl II):II43–II47) Bristol, UK Gut 45 K W Heaton Keywords: functional bowel disorder; functional C. Functional bowel disorders Department of constipation; functional diarrhea; irritable bowel A functional bowel disorder (FBD) is a Medicine, syndrome; functional abdominal pain; functional functional gastrointestinal disorder with symp- abdominal bloating; Rome II McMaster University, toms attributable to the mid or lower gastro- Ontario, Canada intestinal tract, including the irritable bowel E J Irvine The functional bowel disorders and functional syndrome (IBS), functional abdominal bloat- Department of abdominal pain are common and cause much ing, functional constipation, functional di- Medicine, suVering. As these entities are identified by arrhea, and unspecified functional bowel Park-Klinik, symptoms and patient care is highly individual- disorder. Weissensee, Berlin, ized, a symptom-based classification has great Subjects with a FBD may be divided into the Germany following groups: S A Müller-Lissner importance, particularly for use in clinical trials (table 1). Correspondence to: The 1998 Working Team assessed the termi- W Grant Thompson, MD, Abbreviations used in this paper: FBD, functional 7 Nesbitt Street, Nepean, nology and results of relevant clinical research bowel disorder; IBS, irritable bowel syndrome; FAPS, Ontario K2H 8C4, Canada. in order to revise the diagnostic criteria, functional abdominal pain syndrome. II44 Thompson, Longstreth, Drossman, et al

(1) non-patients: those who have never sought Table 2 Supportive symptoms of the irritable bowel health care for the FBD; syndrome (2) patients: those who have sought care for the 1. Fewer than three bowel movements a week FBD; (a) incident cases: those who have 2. More than three bowel movements a day sought care for the FBD for the first time in 3. Hard or lumpy stools 4. Loose (mushy) or watery stools the past year; (b) prevalent cases: those who 5. Straining during a bowel movement have ever sought care for the FBD. 6. Urgency (having to rush to have a bowel movement) Symptoms of a FBD must have been present 7. Feeling of incomplete bowel movement 8. Passing mucus (white material) during a bowel movement for 12 weeks or more within the past 12 9. Abdominal fullness, bloating or swelling months; the 12 weeks need not be consecutive. Diarrhea-predominant The diagnosis always presumes the absence of 1 or more of 2, 4, or 6 and none of 1, 3, or 5 Constipation-predominant a structural or biochemical explanation for the 1 or more of 1, 3, or 5 and none of 2, 4, or 6 symptoms. The Working Team changed the definitions of IBS, functional abdominal bloating and + abnormal stool form (lumpy/hard or loose/ functional constipation from a “disorder” to watery stool); “disorders” to acknowledge multiple patho- + abnormal stool passage (straining, urgency, physiologic possibilities. For IBS, “discomfort” or feeling of incomplete evacuation); was added to “pain” to broaden symptom + passage of mucus; description, and “distension” was deleted. + bloating or feeling of abdominal distension. To clarify how discomfort and pain are tem- These symptoms can be used to subclassify porally related to a change in frequency and patients with predominant diarrhea or consti- form of stool, “onset” was added to the relevant pation for entry into clinical trials (table 2). symptom features. The symptom criteria for IBS were changed (a) by designating the non- DIAGNOSTIC COMMENTS pain-related, the second part of the previous The validity of the symptom criteria is 378 criteria, as nonessential due to their poor clus- supported by patient studies, factor analy- 12 tering in factor analyses12;() their lesser ses on non-patients and long term patient b 9 prevalence in men3; and ( ) the partial duplica- follow up. The history may also reveal c 10 tion in the retained, pain-related criteria. postprandial symptom exacerbation, and oc- Furthermore, these symptoms were clarified by casionally, incontinence and nocturnal pain. replacing the term “altered” with “abnormal.” Symptom worsening during menses and other The criteria for functional constipation were features can falsely suggest a gynecologic 11 expanded due to the overlap between it and the explanation for “chronic pelvic pain.” Other functional anorectal disorders (see Functional non-gastrointestinal somatic symptoms are 5 disorders of the anus and rectum). common. Colonic transit time can be esti- mated by rating self-reported stool appearance according to a stool form scale.12 Fever, rectal C1. Irritable bowel syndrome bleeding, or weight loss require consideration IBS comprises a group of functional bowel dis- of another disorder.13 Abdominal examination orders in which abdominal discomfort or pain reveals no abnormality. Large bowel structural is associated with defecation or a change in examination is recommended to support a bowel habit, and with features of disordered symptom-based diagnosis. The choice of such defecation. examinations should be guided by the age and Surveys of Western populations have re- gender of the patient, the nature and duration vealed IBS in 15–20% of adolescents and of symptoms, and other factors.814 adults, with a higher prevalence in women; the 4 prevalence is variable in other populations. TREATMENT RECOMMENDATIONS IBS has a chronic relapsing course and overlaps A confident diagnosis, explanation, and reas- with other functional gastrointestinal surance are vital therapeutic tools. A graded, disorders.5 It accounts for high direct medical multicomponent approach is advised, depend- expenses6 and indirect costs, including absen- ing on the dominant symptoms, their severity 5 teeism from work. and psychosocial factors.4 Although rigorous therapeutic trials are scarce, popular therapy DIAGNOSTIC CRITERIA includes the use increased dietary fiber such as At least 12 weeks, which need not be wheat bran or bulking agents for constipation, consecutive, in the preceding 12 months of loperimide or diphenoxylate for diarrhea, and abdominal discomfort or pain that has two anticholinergic/antispasmodic agents or low- of three features: dose antidepressants for pain.4 Psychological or (1) Relieved with defecation; and/or behavioral treatments may help some patients. (2) Onset associated with a change in frequency of stool; and/or C2. Functional abdominal bloating (3) Onset associated with a change in form Functional abdominal bloating comprises a (appearance) of stool. group of functional bowel disorders which are dominated by a feeling of abdominal fullness or The following symptoms cumulatively sup- bloating and without suYcient criteria for port the diagnosis of IBS: another functional gastrointestinal disorder. + abnormal stool frequency (for research pur- Few studies adequately separate bloating poses “abnormal” may be defined as >3/day from IBS and other functional disorders, but it and <3/week); occurs in about 15% of community-based Functional bowel disorders and functional abdominal pain II45

populations, usually with a female predomi- patient’s general health, psychological status, nance.15 16 use of constipating medications, dietary fiber intake, and medical illnesses (e.g., hypo- thyroidism) is important. In patients who do DIAGNOSTIC CRITERIA not respond to fiber supplementation, meas- At least 12 weeks, which need not be urements of whole gut transit time21 and consecutive, in the preceding 12 months of: anorectal function22 may be indicated to place (1) Feeling of abdominal fullness, bloating, them in a physiological subgroup. or visible distension; and (2) InsuYcient criteria for a diagnosis of functional dyspepsia, IBS, or other TREATMENT RECOMMENDATIONS functional disorder. Dietary fiber increases fecal bulk by providing indigestible matter and promoting fecal water holding and bacterial proliferation.23 Other DIAGNOSTIC COMMENTS useful bulking agents include psyllium, methyl- Functional bloating is usually absent on awak- cellulose, and calcium polycarbophil. Severely ening and worsens throughout the day. It may constipated patients may respond to polyethe- be intermittent and related to ingestion of spe- lene glycol solution.24 Otherwise, stimulant cific foods. Excessive burping or farting may be laxatives such as bisacodyl, sodium picosul- present, but these are not necessarily related to phate, or sennosides may be tried. Specific the bloating. Diarrhea, weight loss, or nutri- treatment for patients in the anorectal dysfunc- tional deficiency should alert the physician to tion subgroup is discussed in Functional disor- investigate for another disorder. ders of the anus and rectum.

TREATMENT RECOMMENDATIONS There is no proved eVective therapy for C4. Functional diarrhea functional bloating, and its cause is unknown, Functional diarrhea is continuous or recurrent so only education and reassurance are recom- passage of loose (mushy) or watery stools with- mended. The common practice of restricting out abdominal pain. certain “gas-forming” foods may be beneficial A British population survey of stool form (a but even patients with confirmed lactase scale previously validated against symptoms deficiency can drink 250 ml milk with no or and transit time12) revealed liquid stools were negligible bloating.17 the predominant type described by 5.3% of men and 4.3% of women.25 Liquid stools were C3. Functional constipation more common in women under 50 years of age Functional constipation comprises a group of than in older women. functional disorders which present as persist- ent diYcult, infrequent or seemingly incom- DIAGNOSTIC CRITERIA plete defecation. At least 12 weeks, which need not be Constipation occurs in up to 20% of popula- consecutive, in the preceding 12 months of: tions, depending on demographic factors, sam- (1) Liquid (mushy) or watery stools; pling and the definition used. It is more (2) Present >3/4 of the time; and common in women and is usually found to (3) No abdominal pain. increase with age.518

DIAGNOSTIC COMMENTS DIAGNOSTIC CRITERIA Pseudodiarrhea (frequent defecation and ur- At least 12 weeks, which need not be gency with solid stools) must be distinguished consecutive, in the preceding 12 months of from diarrhea. Chronic diarrhea without pain two or more of: is caused by many diseases indistinguishable by (1) Straining in >1/4 defecations; history, which should be excluded by diagnos- (2) Lumpy or hard stools in >1/4 defeca- tic testing. Basic evaluation includes routine tions; blood and stool tests plus sigmoidoscopy with (3) Sensation of incomplete evacuation in biopsy. Features atypical for a functional disor- >1/4 defecations; der (e.g., large volume stools, rectal bleeding, (4) Sensation of anorectal obstruction/ nutritional deficiency, and weight loss) call for blockade in >1/4 defecations more extensive studies of intestinal structure (5) Manual maneuvers to facilitate >1/4 and function—for example, radiography, duo- defecations (e.g., digital evacuation, denal biopsy, and serum hormone assay. support of the pelvic floor); and/or (6) <3 defecations/week. Loose stools are not present, and there are TREATMENT RECOMMENDATIONS insuYcient criteria for IBS. Discussion of possible psychosocial factors, symptom explanation, and reassurance are important. Restriction of foods which seem DIAGNOSTIC COMMENTS provocative may help. Empiric antidiarrheal The physician should clarify what the patient therapy (e.g., diphenoxylate or loperimide) is means by constipation, as patients describe it in usually eVective, especially if taken prophylac- various ways.19 Many, if not most patients actu- tically, such as before meals. The occasional ally have the rectal symptoms of IBS with or patient responds to cholestyramine. Fortu- without lumpy stools.20 Evaluation of the nately, spontaneous remissions are common.26 II46 Thompson, Longstreth, Drossman, et al

C5. Unspecified functional bowel disease (e.g., chronic pancreatitis) or FBD disorder (e.g., IBS). The observation of a lack auto- nomic arousal, eye closure during abdominal examination, and diminished pain behavior An unspecified functional bowel disorder is with stethoscope application to the abdomen defined as functional bowel symptoms that are typical. Multiple abdominal scars are com- do not meet criteria for the previously mon. defined categories.

TREATMENT RECOMMENDATIONS D. Functional abdominal pain Management depends on an eVective doctor– Functional abdominal pain describes continu- patient relationship,27 including reasonable ous, nearly continuous, or frequently recurrent goals, regular appointments and, in some cases, pain localized in the abdomen but poorly concurrent psychological treatment. Analge- related to gut function. sics are ineVective, and narcotics should be Functional abdominal pain is divided into avoided. Concurrent depression should be two categories. treated. Low doses of antidepressants can reduce pain as well as insomnia. Anxiolytic therapy, if used at all, should be limited in D1. Functional abdominal pain duration. Various types of psychotherapy have syndrome been tried without critical evaluation. A multi- Functional abdominal pain syndrome (FAPS), disciplinary pain management program may be also called “chronic idiopathic abdominal the most promising approach.28 pain” or “chronic functional abdominal pain,” describes pain for at least six months that is poorly related to gut function and is associated D2. Unspecified functional abdominal with some loss of daily activities. pain FAPS occurs in 1.7% of people, mainly women, and is associated with significant 5 Unspecified functional abdominal pain is absenteeism from work and physician visits. functional abdominal pain which fails to Over time, patients with FAPS tend to have meet criteria for FAPS (D1). many specialist referrals, diagnostic tests and major abdominal and pelvic operations.27

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20 Probert CSJ, Emmett PM, Cripps HA, et al. Evidence for 24 Klauser AG, Muhldorfer BE, Voderholzer WA, et al. the ambiguity of the term constipation: the role of irritable Polyethylene glycol 4000 for slow transit constipation. Z bowel syndrome. Gut 1994;35:1455–8. Gastroenterol 1995;33:5–8. 21 van der Sijp JRM, Kamm MA, Nightingale JMD, et al. 25 Heaton KW, Radavan J, Cripps H, et al. Defecation Radioisotope determination of regional colonic transit in frequency and timing, and stool form in the general severe constipation. Comparison with radiopaque markers. population: a prospective study. Gut 1992;33:818–24. Gut 1993;34:402–8. 26 Afzalpurkar RG, Schiller LR, et al. The self-limited nature of 22 Wald A, Camara BJ, Freimanis MG, et al. Contribution of chronic idiopathic diarrhea. N Engl J Med 1992;327:1849– evacuation proctography and anorectal manometry to the 52. evaluation of adults with constipation and defecatory diY- 27 Drossman DA. Chronic functional abdominal pain. Am J culty. Dig Dis Sci 1990;25:481–7. Gastroenterol 1996;91:2270–81. 23 Voderholzer WA, Schatke W, Muhldorfer BE, et al. Clinical 28 Kames LD, Rapkin AJ, NaliboV BD, et al.EVectiveness of response to dietary fiber treatment of chronic constipation. an interdisciplinary pain management program for the Am J Gastroenterol 1997;92:95–8. treatment of chronic pelvic pain. Pain 1990;41:41–6.

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