ROME III: The Functional Gastrointestinal Disorders

Toward a new understanding of the functional gastrointestinal disorders For centuries, physicians and historians have recognized that it is common for maladies to aZict the intestinal tract, producing symptoms of pain, nausea, vomiting, bloating, diarrhea, constipation, diYcult passage of food or feces, or any combination. When these symptoms are experienced as severe, or when they impact on daily life, those aZicted often attribute the symptoms to an illness and seek medical care. Traditionally, the physicians caring for these patients will search for inflammatory, infectious, neoplastic, and other structural abnormalities to make a specific diagnosis and oVer specific treatment. Yet as has been common in medical practice, when no structural etiology is found, the patient is diagnosed as having “functional” symptoms and is treated symptomatically. Until recently, the limited scientific knowledge about the pathophysiology of these symptoms, and the need to diagnose by excluding “organic” disease, has led physicians to feel uncertain about the legitimacy of these symptoms as bona fide disorders. Some have felt insecure in their ability to manage patients with these conditions, and might even avoid caring for patients with these complaints. But over the past two decades, two important processes have occurred to legitimize these conditions, and to increase attention toward the research and clinical care of patients with functional gastrointestinal disorders (FGID). The first has been a shift in conceptualizing these disorders from a disease-based, reductionistic model, where the eVort is directed toward identifying a single underlying biological etiology, to a more integrated, biopsychosocial model of illness. 5 The latter model allows for symptoms to be understood as physiologically multidetermined (e.g., altered motility, enhanced visceral sensitivity, brain–gut dysregulation) and as modifiable by sociocultural and psychosocial influences. The second change has been the remarkable growth in investigative techniques that support this newer conceptualization of brain–gut interactions: improved motility assessment, the development of the barostat, imaging of the brain (positron emission tomography (PET), functional magnetic resonance imaging (fMRI)), standardized psychological diagnostic instruments, and the molecular investigation of brain–gut peptides. As a result, over the past two decades, there has been a 10-fold increment in Medline citations about irritable bowel syndrome (IBS), a much larger number of symposia and presentations at national and international meetings about the FGIDs, and increased eVort by pharmaceutical companies to identify and test receptoractive agents to treat these disorders. These developments built support for an international eVort to characterize and classify the FGIDs by investigators and clinicians, pharmaceutical regulatory organizations, pharmaceutical companies, and federal research agencies. The Multinational Working Teams to Develop Diagnostic Criteria for Functional Gastrointestinal Disorders (Rome Committees) began in the mid 1980s as a series of committees that developed consensus criteria for over 20 FGIDs and published them in several documents in Gastroenterology International. These documents were eventually updated and compiled into a book as the Rome criteria. In this supplement, we present the second major eVort of the Rome committees: the update of our growing knowledge of the FGIDs over the past five years. We include five articles that detail the FGIDs based on anatomic region, (esophageal, gastroduodenal, bowel, biliary, anorectal), and a separate article on pediatric FGIDs. We also present several articles summarizing current knowledge on the physiologic (motility/sensation), basic science (brain–gut), and psychosocial aspects of the FGIDs, and provide recommendations for the design of treatment trials for these disorders. In addition, we include the revised (Rome II) diagnostic criteria for the FGIDs developed by consensus of experts and based on existing evidence. Finally, as we enter the new millennium, we offer recommendations for future studies that will help advance this growing field. In this introductory article, I will review the rationale and limitations of a symptom-based diagnostic (Rome II) classification system, discuss the process through which the criteria and consensus information were developed, and briefly summarize the pathophysiological knowledge that is evolving about the FGIDs. More detailed information is provided in the other articles written by the 10 committees.