When In Rome Use the Criteria

Patient Presentation
A 7-year-old male came to clinic with a 3 month history of abdominal pain. The pain occurred at least weekly on different days of the week including the weekend. It occurred during the day and evening but never when asleep. He described it as “just hurting” around his umbilicus without radiation. It was never a sharp pain. He stooled daily or every other day and said that they were “normal” but no one else had seen them. They did not clog up the toilet and he denied blood or mucous in the stools. There was no nausea, emesis, diarrhea, belching, bloating or abnormal tastes in his mouth or throat. The mother stated that sometimes he seemed to have more flatus. The episodes lasted at least 1 hour and during that time he didn’t want to play and would lay down. His mother was worried because “this just seems to happen out of the blue and has been happening more recently. This week he has had it 3 times.” Travel history was negative. He drank public water and had no exposures to animals. The past medical history showed constipation and stool witholding behaviors around the time of toilet training. The family history was positive for occasional abdominal pain in his mother and other maternal relatives without specific diagnoses. There was a paternal adult cousin who “had an ulcer.” The review of systems was negative including no weight loss, fevers, rashes, joint pain, ulcers or urinary symptoms.

The pertinent physical exam showed a well-appearing male who was slightly apprehensive. His weight was 25%, and height was 75% with normal growth velocity. There was no weight loss compared to a sick visit 2 months previously. The abdominal examination showed a soft abdomen that was non-tender without hepatosplenomegaly or masses. His genitourinary examination showed a normal circumcised male with normal cremasteric reflexes. He rectum had a normal anal wink and no fissures or other skin problems were noted. The rest of his examination was negative.

The diagnosis of probable functional abdominal pain was made. The resident physician discussed the patient with the attending and noted that this was most likely functional abdominal pain and had heard of criteria for its diagnosis but was unsure what they were. Together the attending and resident briefly reviewed the Rome III criteria for functional gastrointestinal disorders and felt he met the criteria for functional abdominal pain, although he had not had any laboratory testing to rule out “inflammatory, anatomic, metabolic, or neoplastic process” yet. His history was not consistent with any of these abnormalities. The resident and attending physician discussed the diagnosis and plan with the family. The mother understood but felt reassured that basic laboratory testing would be done (and eventually were negative). She also said that he was always a little anxious and felt that talking with the school counselor may be helpful to him. The patient’s clinical course after 6 weeks of increased fiber intake, talking with the school counselor and parental encouragement of normal activities showed that he was improving. His symptoms had only occurred twice and his repeated physical examination again showed no evidence of an organic problem.

Discussion
Functional gastrointestinal diseases are very common problems throughout the lifespan. Estimates vary but around 13-38% of children and adolescents have weekly abdominal pain and 24% have chronic abdominal pain that last more than 8 weeks. Chronic abdominal pain was extensively studied by John Apley in the 1950’s and since then newer criteria have been developed for distinguishing various types of abdominal pain. See Learning Point below.

A thorough history and physical examination is needed to distinguish these different types of abdominal pain and to evaluate for organic causes. Warning signs of potential organic disease includes:

  • Growth problems and unintentional weight loss
  • Significant GI complaints including emesis, diarrhea and blood in the stool
  • Pain that is not periumbilical (or radiates) or pain at night
  • Systemic symptoms – fever, rash, joint pain, urinary symptoms, apthous ulcers
  • Family history of gastrointestinal organic disease – inflammatory bowel disease, ulcer, celiac disease
  • Abnormal laboratory testing – elevated inflammatory markers, anemia, etc.

Basic laboratory testing may include a basic metabolic panel, complete blood count, C-reactive protein or erythrocyte sedimentation rate, urinalysis and urine culture and stool guaiac. Additional testing may be indicated based on the patient’s history such as stool for ova and parasites with a history of travel or animal exposure, stool C. difficile after antibiotics or breath hydrogen testing for possible malabsorption.

A thorough history, physical examination and basic laboratory testing screens out about 95% of organic pathology. The cause of functional abdominal pain is not entirely understood, but appears to be multimodal – physiological including inflammation and motility issues, psychological including stress and support and genetics. Quality of life is decreased in patients with functional abdominal pain, but many patients do well over time with many having resolution of symptoms in a few weeks to 2 years, and most having improvement in psychosocial functioning.

Multimodal treatment is needed to address functional abdominal pain. The physican-patient-family interaction should be supportive. Physicans can help by encouraging positive attitude towards improving coping with symptoms and maintenance of normal daily living activities. Physicians need to educate families that prompt cure is not realistic and symptom improvement will be gradual. Psychosocial interventions such as cognitive behavioral therapy, guided imagery and relaxation techniques has shown to help improve symptoms. Family therapy to help parents assist their children with improved coping strategies also is helpful. Medication trials have had mixed results including fiber, probiotics, anti-spasmotics, antidepressants, prokinetic agents, acid suppressants, complementary and alternative medications, and restrictive diets. Because of mixed results, some experts will consider using fiber and/or probiotics as relatively benign treatments because there are usually few contraindications to their use and few side effects, and are relatively inexpensive and easy to use.

Learning Point
The Rome III Criteria for abdominal pain-related functional gastrointestinal disorders are:

  • Childhood Functional Abdominal Pain
    • Criteria fulfilled at least once per week for at least 2 months prior to diagnosis
    • Must include all of the following:
      • Episodic or continuous abdominal pain
      • Insufficient criteria for other functional gastrointestinal disorders
      • No evidence of an inflammatory, anatomic, metabolic, or neoplastic process that explains the subject’s symptoms

  • Irritable Bowel Syndrome
    • Criteria fulfilled at least once per week for at least 2 months prior to diagnosis
    • Must include both of the following:
      • Abdominal discomfort (meaning an uncomfortable sensation not described as pain) or pain associated with two or more of the following at least 25% of the time:
        • Improvement with defecation
        • Onset associated with a change in frequency of stool
        • Onset associated with a change in form (appearance) of stool
      • No evidence of an inflammatory, anatomic, metabolic, or neoplastic process that explains the subject’s symptoms

  • Functional Dyspepsia
    • Criteria fulfilled at least once per week for at least 2 months prior to diagnosis
    • Must include all of the following:
      • Persistent or recurrent pain or discomfort centered in the upper abdomen (above the umbilicus)
      • Not relieved by defecation or associated with the onset of a change in stool frequency or stool form (i.e., not irritable bowel syndrome)
      • No evidence of an inflammatory, anatomic, metabolic or neoplastic processthat explains the subject’s symptoms

  • Abdominal Migraine
    • Criteria fulfilled two or more times in the preceding 12 months
    • Must include all of the following:
      • Paroxysmal episodes of intense, acute periumbilical pain that lasts for 1 hour or more
      • Intervening periods of usual health lasting weeks to months
      • The pain interferes with normal activities
      • The pain is associated with 2 of the following:
        • Anorexia
        • Nausea
        • Vomiting
        • Headache
        • Photophobia
        • Pallor
      • No evidence of an inflammatory, anatomic, metabolic, or neoplastic process considered that explains the subject’s symptoms

Questions for Further Discussion
1. What is included in the differential diagnosis of chronic abdominal pain?
2. How does cognitive behavioral therapy work?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Abdominal Pain.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Rome Foundation Inc. Appendix A: Rome III Diagnostic Criteria for Functional Gastrointestinal Disorders. Available from the Internet at http://www.romecriteria.org/assets/pdf/19_RomeIII_apA_885-898.pdf (rev. 2006, cited 4/23/2013).

Ammoury RF, Pfefferkorn Mdel R, Croffie JM. Functional gastrointestinal disorders: past and present. World J Pediatr. 2009 May;5(2):103-12.

Chiou E, Nurko S. Management of functional abdominal pain and irritable bowel syndrome in children and adolescents. Expert Rev Gastroenterol Hepatol. 2010 Jun;4(3):293-304.

Ringel Y, Ringel-Kulka T. The rationale and clinical effectiveness of probiotics in irritable bowel syndrome. J Clin Gastroenterol. 2011 Nov;45 Suppl:S145-8.

Quigley EM, Abdel-Hamid H, Barbara G, Bhatia SJ, Boeckxstaens G, De Giorgio R, Delvaux M, Drossman DA, Foxx-Orenstein AE, Guarner F, Gwee KA, Harris LA, Hungin AP, Hunt RH, Kellow JE, Khalif IL, Kruis W, Lindberg G, Olano C, Moraes-Filho JP, Schiller LR, Schmulson M, Simren M, Tzeuton C.
A global perspective on irritable bowel syndrome: a consensus statement of the World Gastroenterology Organisation Summit Task Force on irritable bowel syndrome. J Clin Gastroenterol. 2012 May-Jun;46(5):356-66.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital