Manning criteria in irritable bowel syndrome: its diagnostic significance

Making a Confident Diagnosis of Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is among the most common diagnoses made by medical providers and its symptoms are common causes for health care consultation. IBS is characterized by abdominal pain associated with abnormal stool consistency and/or frequency and is widely considered a diagnosis of exclusion, despite abundant evidence contradicting such an approach. A positive diagnosis is achieved through application of symptom-based clinical criteria, careful history and physical examination, evaluation for alarm sign/symptoms, and judicious use of diagnostic testing. This article reviews the symptom-based criteria for IBS and utility of diagnostic tests commonly included in the evaluation of IBS symptoms.

A systematic review and meta-analysis of the associations between endometriosis and irritable bowel syndrome

Endometriosis and Irritable Bowel Syndrome (IBS) are common conditions among young women of reproductive age. The etiologies to the diseases are uncertain, but multifactorial pathophysiology has been proposed for each of them. Many studies have examined the two conditions separately, but the literature on the associations between endometriosis and IBS is sparse. However, there is an increasing amount of research on how endometriosis patients are likely to also have a diagnosis of IBS. Furthermore, endometriosis shares several features with IBS, such as low-grade inflammation and visceral hypersensitivity. This systematic review summarized published original articles in English that have compared associations between endometriosis and IBS. The inclusion criteria for articles in the review were: i) endometriosis was diagnosed by surgical methods, ii) gastrointestinal symptoms were examined in a structured manner and iii) IBS was diagnosed by Rome criteria. From the initial 254 publications identified on PubMed, Web of Science and EMBASE, 13 fulfilled the criteria and could finally be included in the summary. The findings from the review showed that women diagnosed with endometriosis seem to have a twofold or threefold risk to also fulfill the criteria for IBS. The summary risk estimate of the four studies included in the meta-analysis was 2.39 (95 % confidence interval: 1.83-3.11). In women initially diagnosed with IBS, some studies reported a threefold risk of having an endometriosis diagnosis. Despite the strong associations reported between the two conditions, this review also revealed a gap in adjusting for factors that may have affected the expression of gastrointestinal symptoms, e.g., phases of the menstrual cycle, medication and psychological aspects, which may have interpretation of the reviewed articles' results. The conclusion of this review is that there is a coexistence of gastrointestinal symptoms fulfilling the Rome criteria in patients with endometriosis, but it is uncertain whether there is a true comorbidity between endometriosis and IBS, or whether the gastrointestinal symptomatology in endometriosis depends on medication. Additionally, the adequacy of the Rome criteria to differentiate IBS from the shared symptomatology of other diseases with visceral hypersensitivity must be further evaluated.

Bowel symptoms are associated with hypovitaminosis D in individuals with medically complicated obesity

We reported that 30% of individuals with medically complicated obesity have bowel symptoms, suggesting irritable bowel syndrome, but this prevalence of bowel symptoms is not related to body mass index or diabetes mellitus. Hypovitaminosis D is common in individuals with obesity and type 2 diabetes mellitus and is associated with depressive symptoms. Because antidepressants improve global symptoms in individuals with bowel symptoms, we hypothesize that the high prevalence of bowel symptoms in medically complicated obesity is associated with hypovitaminosis D. This is a single-institution, retrospective cohort study performed in a large, urban community teaching hospital. Over 2 years, individuals considering bariatric surgery completed a Manning symptom questionnaire to quantify bowel symptoms. Serum 25-hydroxy vitamin D was ordered, and the results were recorded for all individuals. Among 271 subjects, 229 subjects (80% women, 20% men; 67% black, 31% white; age range: 23-73 years; body mass index range: 35-91 kg/m²) completed 25-hydroxy vitamin D testing. Sixty-seven subjects (29%) have 3 to 6 Manning bowel symptoms, suggesting irritable bowel syndrome; 84 (37%) have type 2 diabetes; and 180 (79%) had vitamin D insufficiency. There are significant negative associations between Manning bowel symptoms and vitamin D concentrations in subjects with obesity (P = .01) and with type 2 diabetes mellitus and obesity (P = .007). The results support our hypothesis that the high prevalence of bowel symptoms in people with medically complicated obesity is associated with hypovitaminosis D. A prospective study is required to evaluate vitamin D supplementation and relief of bowel symptoms in people with medically complicated obesity.

Microscopic colitis: a missed diagnosis among patients with moderate to severe irritable bowel syndrome

OBJECTIVE

Irritable bowel syndrome (IBS) is a very common condition in general practise, affecting 10-20% of the population in the Western world. The clinical picture of diarrhoea-predominant IBS (IBS-D) resembles other chronic diarrhoeic conditions, such as microscopic colitis (MC). It is impossible to separate these by clinical examinations or lab-tests that can be done in general practise. The aim of this study was to detect any missed diagnoses when only using a symptom-based approach for the diagnosis of IBS.

MATERIAL AND METHODOLOGY

We examined 87 participants diagnosed with IBS by the Rome III criteria. All the participants underwent full clinical examination, lab-tests and colonoscopy including mucosa biopsies for histological examination.

RESULTS

The histological analysis revealed four cases of MC in participants who for years had been diagnosed with IBS. We found no biochemical or clinical markers that made it possible to differentiate between IBS and MC. MC was only found in the participants diagnosed with IBS-D.

CONCLUSION

When long-lasting, unresolved diarrhoeic conditions are present in patients over 45-50 years of age, colonoscopy with biopsy should be performed to rule out MC and other pathologies before diagnosing IBS. In younger patients with pronounced watery diarrhoea, one should consider colonoscopy individually if there is no response to IBS-treatment.

Systematic review with meta-analysis: the accuracy of diagnosing irritable bowel syndrome with symptoms, biomarkers and/or psychological markers

BACKGROUND

Irritable bowel syndrome (IBS) is a complex, heterogeneous disease which can be challenging to diagnose. No study has identified and assessed the accuracy of all available methods of diagnosing IBS.

AIM

To conduct a systematic review of the literature to identify and assess accuracy of symptom-based diagnostic criteria, biomarkers, psychological markers or combinations thereof.

METHODS

MEDLINE, EMBASE and EMBASE Classic were searched (until April 2015) to identify studies reporting accuracy of available methods to diagnose IBS in adult populations. Eligible studies assessed accuracy of these diagnostic tests against an accepted reference standard. Data were extracted to calculate positive and negative likelihood ratios, with 95% confidence intervals (CIs), of the diagnostic test utilised. Where more than one study used the same test, data were pooled in a meta-analysis.

RESULTS

Twenty-two studies (7106 patients) were eligible. Positive and negative likelihood ratios of the current gold standard, the Rome III criteria, were 3.35 (95% CI: 2.97-3.79) and 0.39 (95% CI: 0.34-0.46), similar to other symptom-based criteria. Eleven biomarkers performed no better than symptom-based criteria. Psychological markers performed well in one study. Five different combinations were assessed. The best in terms of positive likelihood ratio was faecal calprotectin, intestinal permeability and Rome I criteria (26.4; 95% CI: 11.4-61.9), and in terms of negative likelihood ratio serum-based biomarkers and psychological markers (0.18; 95% CI: 0.12-0.25).

CONCLUSIONS

Symptom-based diagnostic criteria, biomarkers and psychological markers performed modestly in predicting IBS. Combining symptoms with markers appears more effective, and may represent the way forward in the diagnosis of IBS.

Diagnosis of IBS: symptoms, symptom-based criteria, biomarkers or 'psychomarkers'?

IBS is estimated to have a prevalence of up to 20% in Western populations and results in substantial costs to health-care services worldwide, estimated to be US$1 billion per year in the USA. IBS remains difficult to diagnose due to its multifactorial aetiology, heterogeneous nature and overlap of symptoms with organic pathologies, such as coeliac disease and IBD. As a result, IBS often continues to be a diagnosis of exclusion, resulting in unnecessary investigations. Available methods for the diagnosis of IBS-including the current gold standard, the Rome III criteria-perform only moderately well. Visceral hypersensitivity and altered pain perception do not discriminate between IBS and other functional gastrointestinal diseases or health with any great accuracy. Attention has now turned to developing novel biomarkers and using psychological markers (so-called psychomarkers) to aid the diagnosis of IBS. This Review describes how useful symptoms, symptom-based criteria, biomarkers and psychomarkers, and indeed combinations of all these approaches, are in the diagnosis of IBS. Future directions in diagnosing IBS could include combining demographic data, gastrointestinal symptoms, biomarkers and psychomarkers using statistical methods. Latent class analysis to distinguish between IBS and non-IBS symptom profiles might also represent a promising avenue for future research.

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.

Prevalence of organic colonic lesions in patients meeting Rome III criteria for diagnosis of IBS: a prospective multi-center study utilizing colonoscopy

BACKGROUND

It remains unknown whether the Rome III criteria can exclude organic colonic lesions prior to the diagnosis of irritable bowel syndrome (IBS). We evaluated the colonoscopy results of patients meeting the Rome III criteria for the diagnosis of IBS to determine the presence of organic colonic lesions.

METHODS

This study was prospectively conducted at 17 centers in Japan. We enrolled 4528 patients who underwent diagnostic colonoscopy examinations. The diagnosis of IBS was evaluated by questionnaire results according to the Rome III criteria.

RESULTS

We evaluated 4178 patients (350 were excluded because of incomplete data or previous colonic surgery), of whom 203 met the Rome III criteria (mean age 57.9 years; range 14-87 years) prior to the diagnostic colonoscopy examination. We identified organic colonic diseases in 21 of these 203 patients (10.3 %) , and these disease were also identified in 338 (8.5 %) of 3975 patients who did not fulfill the Rome III criteria. There were no differences in regard to the prevalence of organic colonic diseases between patients who did and did not fulfill the Rome III criteria.

CONCLUSIONS

The prevalence of organic colonic diseases in patients who met the Rome III criteria was at an acceptably low level, indicating that the Rome III criteria are adequately specific for the diagnosis of IBS without performing a colonoscopy examination.

Symptom-based diagnostic criteria for irritable bowel syndrome: the more things change, the more they stay the same

Medical students are taught that 90% of all diagnoses are made through careful assessment of the patients' symptoms. Clinicians now rely heavily on techniques such as endoscopy or radiology before making a definitive diagnosis of organic disease. Most gastroenterologists would require endoscopic confirmation before labeling a patient as having peptic ulcer disease and would make a diagnosis of Crohn disease based on small bowel radiology or colonoscopy. However, the most common causes of symptoms of the gastrointestinal tract are functional. It is important that clinicians obtain a thorough history so that the disorder of the patient can be accurately defined.

The Differences in Prevalence and Sociodemographic Characteristics of Irritable Bowel Syndrome According to Rome II and Rome III

BACKGROUND/AIMS

Irritable bowel syndrome (IBS) is one of the most frequently observed disorders by primary care and practitioners. The aim of this study was to estimate the prevalence of IBS using the Rome II and III criteria in the general Korean population and also to compare sociodemographic differences between subjects diagnosed by these criteria.

METHODS

Telephone interview surveys were performed with a total of 1,009 individuals in Korea, 15 years of age or older. The questionnaire, based on the Rome II and III criteria, was validated.

RESULTS

Among the 1,009 subjects, the prevalence of IBS was 8.0% under the Rome II criteria (81 subjects; 6.4%, male; 9.6%, female), and 9.0% (91 subjects; 7.0%, male; 11.0%, female) under the Rome III criteria. The accordance rate of Rome II and III was 73.5%. Both groups showed highest frequency in the age of 30s (13.9% vs. 15.3% respectively). Female subjects showed a higher prevalence than male subjects under Rome III (91 subjects; 11.0% in female, 7.0% in male; p < 0.05), but not under Rome II criteria. Many patients older than 50 years were added when analyzed under the Rome III criteria, but not under the Rome II criteria (p = 0.017).

CONCLUSIONS

The Rome III criteria were less restrictive and showed good agreement with the Rome II criteria. The prevalence of IBS was increased in young women.

Systematic review: accuracy of symptom-based criteria for diagnosis of irritable bowel syndrome in primary care

BACKGROUND

Despite the trend towards making a positive diagnosis of irritable bowel syndrome (IBS), many health care providers approach IBS as a diagnosis of exclusion.

AIM

To summarize available evidence on the diagnostic performance of symptom-based IBS criteria in excluding organic diseases, and of individual signs and symptoms in diagnosing IBS and to additionally assess the influence of sources of heterogeneity on diagnostic performance.

METHODS

We searched PubMed and EMBASE and screened references. Studies were selected if the design was a primary diagnostic study; the patients were adults consulting because of non-acute abdominal symptoms; the diagnostic test included an externally validated set of IBS criteria, signs, or symptoms. Data extraction and quality assessment were performed by two reviewers independently. The review adhered to the most recent guidelines as described in the Cochrane Diagnostic Reviewers' Handbook.

RESULTS

A total of 25 primary diagnostic studies were included in the review. The performance of symptom-based criteria in the exclusion of organic disease was highly variable. Patients fulfilling IBS criteria had, however, a lower risk of organic diseases than those not fulfilling the criteria.

CONCLUSIONS

With none of the criteria showing sufficiently homogeneous and favourable results, organic disease cannot be accurately excluded by symptom-based IBS criteria alone. However, the low pre-test probability of organic disease especially among patients who meet symptom-based criteria in primary care argues against exhaustive diagnostic evaluation. We advise validation of the new Rome III criteria in primary care populations.

Diagnosis of irritable bowel syndrome

Because there are no reliable biological or laboratory markers associated with the condition, the diagnosis of irritable bowel syndrome(IBS) is based on patient descriptions of common symptoms such as abdominal pain accompanied by changes in stool form or frequency and associated symptoms such as bloating and distension. With the development and refinement of symptom-based criteria for the diagnosis of IBS, the traditional need for a negative diagnostic evaluation has been questioned. This article evaluates the diagnostic characteristics of various symptom-based criteria in routine clinical practice and reviews the data regarding the yield of the multiple commonly used diagnostic tests in patients with suspected IBS.

Diagnostic yield of alarm features in irritable bowel syndrome and functional dyspepsia

OBJECTIVE

The diagnostic value of the addition of alarm symptoms in distinguishing functional from organic gastrointestinal disease remains uncertain. We aimed to establish the value of alarm features in differentiating between organic disease and irritable bowel syndrome (IBS) and functional dyspepsia (FD).

METHODS

A total of 568 consecutive patients (63% female; mean age 44.7 years) completed a detailed symptom questionnaire and then received a complete diagnostic workup, as required. Questionnaire data were collected prospectively and audited retrospectively; the treating physician was blinded to the results of the questionnaires. Patients were coded and allocated to the following diagnostic groups: IBS, FD, organic diseases of the upper gastrointestinal tract, or organic diseases of the lower gastrointestinal tract. Logistic regression was used to identify the best subset of symptoms that discriminated organic disease from functional illness. Separate models compared IBS (n = 214) with diseases of the lower gastrointestinal tract (n = 66), and FD (n = 70) with diseases of the upper gastrointestinal tract (n = 250).

RESULTS

Age (50 years at symptom onset: odds ratio (OR) 2.65 (95% confidence interval 1.4-5.0); p = 0.002) and blood on the toilet paper (OR 2.7 (1.4-5.1);p = 0.002) emerged as alarm features that discriminated IBS from lower gastrointestinal illness. A diagnosis of IBS was typically associated with female sex (OR2.5 (1.3-4.6); p = 0.004), pain on six or more occasions in the previous year (OR 5.0 (2.2-11.1); p<0.001), pain that radiated outside of the abdomen (OR 2.9 (1.4-6.3); p = 0.006), and pain associated with looser bowel motions (OR 2.1 (1.1-4.2); p = 0.03). A model incorporating three Manning criteria and alarm features yielded a correct diagnosis of IBS in 96% and a correct diagnosis of organic disease in 52% of cases. Alarm features did not discriminate FD from upper gastrointestinal disease. Patients with FD were significantly more likely to report upper abdominal pain (OR 3.7 (1.7-8.3); p = 0.002) and significantly less likely to report aspirin use (OR 0.26 (0.1-0.6); p = 0.001). The predictive value of symptoms in diagnosing FD was only 17%.

CONCLUSIONS

Symptoms plus alarm features have a high predictive value for diagnosing IBS but the predictive value for a diagnosis of FD remains poor. Current criteria for the diagnosis of IBS should incorporate relevant alarm features to improve the diagnostic yield.

Irritable bowel syndrome

Irritable bowel syndrome is a biopsychosocial disorder characterized by dysregulation of intestinal motor, sensory, and central nervous system functions. It is associated with significant disability and health-care costs. The traditional diagnostic approach leads to excessive investigation for many patients. A reductionist approach of focusing on evaluation and treatment of a single mechanism is unlikely to prove effective. Identification of the characteristic symptom pattern is the key to cost-effective management. A strong patient-physician relationship is essential for a successful outcome. Optimal outcome is predicated on an individualized treatment plan that integrates pharmacologic and behavioral modalities.

Irritable bowel syndrome: an update on therapeutic modalities

Irritable bowel syndrome (IBS) is the most common condition that a physician faces in the GI clinic. Of the general population, 10 - 25% suffer from symptoms judged to be IBS. The negative impact of this disease includes not only pain, suffering and direct medical expenses but also significant social and job-related consequences. IBS can be the result of dysfunction in any part of the brain-gut axis: alterations in the CNS caused by psychological or other factors, abnormal gastrointestinal motility, or heightened visceral sensations. Diagnosis is based on either the Manning or Rome-II criteria. Education, reassurance and emotional support are the cornerstones of successful treatment. The mainstays of the current therapeutic approach continue to be: stress management strategies, dietary modification entailing addition of dietary fibre and pharmacotherapy. Pharmacotherapy is still limited to treating symptoms. Newer drugs that modulate motility or drugs that modulate visceral sensation may be useful in selected cases. Psychopharmacological agents are useful in the treatment of IBS, especially in those with psychological co-morbidity. Alternative therapies such as homeopathy, acupuncture, special diets, herbal medication and several forms of psychological treatments and hypnotherapy are sought by many patients and are now being offered by physicians as treatment options, either alone or in conjunction with conventional forms of therapy in patients with refractory symptoms.

Diagnostic criteria for the irritable bowel syndrome

The Rome criteria represent a consensus viewpoint based on currently available data, but their development certainly does not establish that the content is truly indicative of a specific disease process. There is a limit to the repertoire of gastrointestinal symptoms; because of the low specificity of symptoms, it is understandable that symptoms alone are unlikely to be accurate enough. However, in the absence of a reproducible and accepted biological marker, symptoms currently remain the primary means of identifying and recruiting patients for research. All diagnostic criteria will continue to be controversial until the pathophysiology of irritable bowel syndrome (IBS) is better understood and treatment more appropriately targeted to relevant disturbances. The aim of this review is to present the current Rome criteria and critically evaluate the arguments for and against the individual components being included as part of the criteria.

Likely impacts of recruitment site and methodology on characteristics of enrolled patient population: irritable bowel syndrome clinical trial design

Approximately 15-20% of the general population of many western countries fulfill clinical diagnostic criteria for irritable bowel syndrome (IBS) and nearly 50% of referrals and follow-up appointments in hospital gastroenterology clinics are for functional bowel disorders. IBS is a common problem in the community, in primary care (general practice) and in secondary care (hospital, usually ambulatory) settings, and is also seen in tertiary (referral) centers, providing at least four potential settings for recruitment of patients into clinical trials. However, little is known about the influences that cause patients to choose different health-care settings or to stay away from the health-care system as "nonconsulters." Also, it is not known if patients seen at different health-care settings differ from each other. The aim of this review is to address the following questions: To what extent do subjects identified and enrolled in these settings differ from each other? What is the likely impact of different recruitment methods on subject selection? What problems for the interpretation and generalizability of data from clinical trials might these differences pose? What is the role of the sociomedical context (cultural beliefs and values and the structure of the health-care system) in different countries on the interpretation of clinical studies?

Recommendations for the management of irritable bowel syndrome in family practice. IBS Consensus Conference Participants

To help family physicians manage patients with irritable bowel syndrome (IBS), a consensus conference was convened in June 1997 at which 5 internationally recognized experts in IBS presented position papers on selected topics previously circulated to the conference participants. Five working groups comprising family physicians, gastroenterologists and allied health care professionals from across Canada were then charged with developing recommendations for the diagnosis, patient education, psychosocial management, dietary advice and pharmacotherapy, respectively. An evidence-based approach was used where possible; otherwise, recommendations were made by consensus. The participants concluded that family physicians can make a positive diagnosis of IBS using symptom criteria. The pathophysiology is poorly understood, but motility and sensory disturbances appear to play a role. Neither psychological nor specific dietary factors cause IBS, but both can trigger symptoms. Drug therapy is not recommended for the routine treatment of IBS, but short-term trials of drug therapy may be targeted to predominant symptoms in selected patients. A step-wise, patient-centred approach to management is outlined.

Irritable bowel syndrome. Managing the patient with abdominal pain and altered bowel habits

Irritable bowel syndrome is a common complex of syndromes thought to be generated by a motility or sensory disturbance of the gastrointestinal tract. It is a frequent cause of chronic abdominal pain and altered bowel habits. Patients who seek medical attention for irritable bowel syndrome often do so because of psychosocial factors. Therapy remains largely empirical, directed toward the relief of symptoms in the context of a supportive physician-patient relationship.