Rome IV Diagnostic Criteria for Constipation
INSTRUCTIONS
- Use in patients with symptoms suggestive of constipation for at least the last 3 months with symptom onset ≥6 months ago.
- Do NOT use in patients with alarm symptoms such as GI bleeding, unexplained iron deficiency anemia, unintentional weight loss, palpable abdominal mass, family history of colon cancer or symptom onset ≥50 years of age and not yet screened for colon cancer, or sudden/acute onset of new change in bowel habit.
- Patients presenting with symptoms suggestive of constipation for at least the last 3 months with symptom onset ≥6 months ago.
- Do NOT use in patients with alarm symptoms such as:
- Signs or symptoms of gastrointestinal bleeding.
- Unexplained iron deficiency anemia.
- Unintentional weight loss.
- Palpable abdominal mass or lymphadenopathy on exam.
- Family history of colon cancer and have not had age-appropriate colon cancer screening.
- Onset of symptoms age ≥50 years and have not had age-appropriate colon cancer screening.
- Sudden or acute onset of new change in bowel habit.
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Developed in order to diagnose functional constipation in the absence of secondary causes of constipation. These secondary causes may include, but are not limited to, mechanical obstruction, medication side effects, and systemic illness.
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Patients are often on medications to treat constipation. These criteria should be used in the setting of what symptoms occur when they are not using medications. Start questions with “When you are not on medications to treat constipation...” For example: “When you are not on medications to treat constipation, how often do you strain to have a bowel movement?”
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If abdominal pain is present or is a predominant symptom in addition to constipation symptoms, a diagnosis of the constipation subtype of irritable bowel syndrome (IBS) should be considered.
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To determine stool form, use the Bristol Stool Form Scale. It is important that patients look at both the pictures and the text.
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Helps diagnose functional constipation in the absence of secondary causes of constipation.
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Making a diagnosis will help guide need for further work-up and management.
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Can be used to discuss signs and symptoms of constipation with patients.
Diagnostic Result:
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Advice
If diagnosis not met (negative):
Symptoms unlikely to be caused by functional constipation. Consider further assessment as clinically indicated.
If meets diagnosis (positive):
Likely diagnosis of functional constipation. Consider initiating treatment.
Management
- Management of functional constipation may include:
- Ensure adequate dietary fiber intake and supplementation if required.
- Osmotic laxatives (e.g. PEG-3350, lactulose).
- Stimulant laxatives (e.g. bisacodyl, senna).
- Secretagogues (e.g. linaclotide, lubiprostone).
- 5-HT4 receptor agonist (e.g. prucalopride, but note this is not currently FDA approved).
- The choice of therapy is outside the scope of this calculator and will depend on clinical context.
Critical Actions
This calculator should only be used in patients where a secondary cause of constipation (e.g. mechanical obstruction, systemic illness, medications) is not suspected based on clinical history, physical exam, and initial workup.
Formula
The following three criteria must be fulfilled for the last 3 months with symptom onset ≥6 months ago:
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Must have ≥2 of the following, each for >1/4 (25%) of defecations except (f):
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Straining.
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Lumpy or hard stools (form 1 or 2 on the Bristol Stool Form Scale - see below).
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Sensation of incomplete evacuation.
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Sensation of anorectal obstruction/blockage.
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Manual maneuvers to facilitate defecation (e.g. digital evacuation, pelvic floor support).
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<3 spontaneous bowel movements per week.
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Loose stools rarely present without use of laxatives.
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Does not meet Rome IV Criteria for IBS.
Bristol Stool Form Scale:
From Chumpitazi 2016.
Evidence Appraisal
The Rome criteria were initially developed as a way to classify and diagnose the various functional gastrointestinal disorders such as dyspepsia, functional constipation, and irritable bowel syndrome (IBS) based primarily on symptoms. The updated Rome IV was designed to make the criteria easier to use clinically, incorporate investigations where appropriate and psychosocial aspects of these disorders, and improve its applicability to other countries and cultures.
The development of the Rome IV questionnaires began with a survey of 1,162 adults without gastrointestinal disorders to determine the frequency in the US general population of various gastrointestinal symptoms. The 90th percentile of symptom frequency was used to define what was considered an abnormal frequency of symptoms. Based on this, diagnostic questionnaires were created and reviewed by clinical experts. These questionnaires were validated in 843 patients from gastroenterology clinics. In functional constipation, the sensitivity of this criteria was 32.2% and the specificity was 93.6%.
Literature
Original/Primary Reference
Drossman DA. Functional Gastrointestinal Disorders: History, Pathophysiology, Clinical Features and Rome IV. Gastroenterology. 2016; 150(6):1262-1279.Other References
Mearin F, Lacy BE, Chang L, et al. Bowel Disorders. Gastroenterology. 2016; 150(6):1393-1407.Chumpitazi BP, Self MM, Czyzewski DI, Cejka S, Swank PR, Shulman RJ. Bristol Stool Form Scale reliability and agreement decreases when determining Rome III stool form designations. Neurogastroenterol Motil. 2016;28(3):443-8.
About the Creator
Douglas Drossman, MD, is professor emeritus of medicine and psychiatry at the University of North Carolina School of Medicine. He is also the founder of the Drossman Center for the Education and Practice of Biopsychosocial Care and Drossman Consulting, LLC. Dr. Drossman has written over 500 articles and book chapters, has published two books, a GI procedure manual and a textbook of functional GI disorders (Rome I-IV), and serves on six editorial and advisory boards.
To view Dr. Douglas Drossman's publications, visit PubMed
- Colleen Parker, MD