Functional Gastrointestinal Disorders - Rome Foundation

1 SECTION I: FGIDs: BACKGROUND INFORMATIONF unctional Gastrointestinal Disorders : History, Pathophysiology,Clinical Features, and Rome IVDouglas A. DrossmanCenter for Education and Practice of Biopsychosocial Care, Drossman Gastroenterology; Center of Functional GI and MotilityDisorders, University of North Carolina; and Rome Foundation , Chapel Hill, North CarolinaFunctional Gastrointestinal Disorders (FGIDs), the mostcommon diagnoses in gastroenterology, are recognized bymorphologic and physiological abnormalities that oftenoccur in combination including motility disturbance,visceral hypersensitivity, altered mucosal and immunefunction, altered gut microbiota, and altered central ner-vous system processing. Research on these gut braininteraction Disorders is based on using specific diagnosticcriteria. The Rome Foundation has played a pivotal role increating diagnostic criteria, thus operationalizing thedissemination of new knowledge in thefield of IV is a compendium of the knowledge accumulatedsince Rome III was published 10 years ago.

2 It improvesupon Rome III by: (1) updating the basic and clinicalliterature; (2) offering new information on gut microenvi-ronment, gut brain interactions, pharmacogenomics, bio-psychosocial, gender and cross-cultural understandings ofFGIDs; (3) reduces the use of imprecise and occasionallystigmatizing terms when possible; (4) uses updated diag-nostic algorithms; and (5) incorporates information on thepatient illness experience, and physiological subgroups orbiomarkers that might lead to more targeted introductory article sets the stage for the remaining17 articles that follow and offers a historical overview ofthe FGID field, differentiates FGIDs from motility andstructural Disorders , discusses the changes from Rome III,reviews the Rome committee process, provides a bio-psychosocial pathophysiological conceptualization ofFGIDs, and offers an approach to patient : Functional GI Disorders ; Rome Foundation ; RomeCriteria; History; Biopsychosocial Model; Neuro-gastroenterology; Patient Provider Relationship; Rome IV;Classification; Diagnosis; Treatment descriptions of Functional gastrointestinalsymptoms have been noted for centuries, the func-tional Gastrointestinal Disorders (FGIDs) emerged only overthe past several decades.

3 Our conceptual understanding oftheir origins and clinical features evolved from a dualisticand reductive perspective to a more comprehensive bio-psychosocial model,1,2and the scientific bases for symptomgeneration changed from being Disorders of motility to themore inclusive disturbances of neurogastroenterology andbrain gut evolution has legitimizedFGIDs to patients and health care providers and nurturedthe science to better characterize these Disorders and pro-duce new drug discoveries and Rome Foundation has its origins in the late 1980s, at atime when there was little understanding of the pathophysi-ology of FGIDs, no established classification system, and noguidelines for standardized research of the patients. Subse-quently, the Foundation has played a pivotal role in oper-ationalizing the research and disseminating the knowledgesurrounding these Disorders . Also, by gathering experts fromaround the world who use more positive parameters fordiagnosis and perform fewer studies to exclude other disease,the Rome Foundation identifies experts who are in the bestposition to provide guidelines for diagnosis and of the FunctionalGastrointestinal Symptoms andDisorders and the Roleof Psychosocial FactorsThroughout recorded history, the bowels and intestinalactivity have had meanings that go beyond their actualfunction.

4 They usually are considered private and shroudedin mystery. Their dysfunction is linked to embarrassment,emotion, and shame, and proper bowel functioning isthought to be required for general well-being. We alsorecognize bowel function and dysfunction as being relatedclosely to stress and emotion: Ifind this hard to swallow, I cannot stomach that any longer, and I feel butterflies inmy stomach. Conversely, and likely as evolving for healthbenefit, intestinal contents and feces are noxious to thesenses; the sight, smell, and touch of these can lead toavoidant emotional responses, nausea, and vomiting. Thus,brain and gut more than any other organ systems arehardwired; each has a nervous system that is linked andderived from the same anlage, the embryonic neural brain gut connection also explains why stress andpsychological factors are linked so closely to gut function anddysfunction, Gastrointestinal symptoms, illness, and how these factors relate to one another hasevolved from the changing mores, belief systems, orexplanatory (folk) models of the time.

5 Explanatory models ofAbbreviations used in this paper:CNS, central nervous system; FGID, Functional Gastrointestinal disorder; GI, Gastrointestinal ; IBS, irritablebowel syndrome; SOD, sphincter of current article 2016 by the AGA Institute0016-5085/$ 2016;150:1262 1279 Functional GI OVERVIEW illness and disease arise and change in response to newtechnologies and the need for clinical solutions; however,new models require acceptance by society based on theoriesthat may have existed for centuries and across , the perception of symptoms may be consideredproblems in one population, but ignored in another. Thisperception can occur simply based on prevalence, in thatsymptoms that are more common would be considerednormal. For example, among lower socioeconomic MexicanAmericans in the Southwest, diarrhea is common and is notusually perceived as an illness requiring health care seeking,4whereas in other sectors of society, diarrhea is considered anillness to be investigated or important influencing factor for a symptom tobe perceived as an illness relates to its congruence withdominant or major value orientations: that is, how it isrecognized by the society.

6 In some nonliterate societies, thedescription of hallucinations is accepted with interest,possibly indicating specialness, having magical powers, orconnecting with spiritual beings. However, in Western so-ciety, the admission of a hallucination would be considereda potentially serious medical problem possibly caused bypsychosis or drug and cultural values alsocan affect even the development or nondevelopment ofsymptoms. Margaret Mead noted that nausea, which is acommon and acceptable part of pregnancy in the West, doesnot occur among the Arapesh of New Guinea, because thereis denial that a child exists until shortly before section traces cultural influences on research andknowledge of Gastrointestinal symptoms and illness,consequently leading to the identification and categorizationof Functional Gastrointestinal (GI) Through the Late 19th Century:Holism and Cartesian DualismThe possibility that passions or emotions could lead tothe development of medical disease wasfirst proposed bythe Greek physician Claudius Galen and has been upheld bymedical writers into the 21st century.

7 This supposition isnot surprising because we observe the effects of intenseemotion on autonomic arousal, leading to diarrhea, theproduction of chest or abdominal pain, or even today, when the pathophysiology of a disease isnot clearly related to a particular, usually structural, etiol-ogy, it is common to attribute the disease to a psychogeniccause, and this has its roots in the historical tensionbetween holism and concept of holism, from the Greekholos, or whole,wasfirst proposed by Plato, Aristotle, and Hippocrates inancient postulates that the mind and bodyare integrated and inseparable, and the study of medicaldisease must take into account the whole person rather thanmerely the diseased part. This approach accepts medicalsymptoms and behavioral disturbances as legitimate fea-tures of the individual and traditionally has existed inEastern , by the 17th century in Western Europe,the concept of holism was eclipsed by the influence of thephilosopher Ren Descartes, who in 1637 proposed theseparation of the thinking mind (res cogitans) fromthe machine-like body (res extensa).

8 2 Descartes s concept ofmind body separation rapidly took hold on the backdrop ofevolving sociocultural influences, at the time relating to theseparation of church and state. Mind body dualism hadprofound effects on how medical disease became concep-tualized. Until that time, the body could not be dissectedbecause the spirit was thought to reside there. Medicalinvestigation based on the writings of Galen related toobservation of the body and its humors. When the mind body dualism construct lifted the mind and soul from therealm of the body, human dissection then would bepermitted, and this led to emerging knowledge of diseasepathology. Over the next few centuries, the morphologicstudy of disease through pathology, then histopathology,radiology, and nuclear imaging, led to many new diagnosesand treatments for , with a morphologic construct, there was nounderstanding of symptoms or behaviors in the absence ofpathology. In the 17th century, patients showing these fea-tures were believed to be under demonic possession and, inlater centuries, were considered insane.

9 They were rele-gated to asylums and were excluded from scientific , another result of Cartesian mind bodydualism is that the study of behavioral abnormalities andmental illness was marginalized; the mind as the seat of thesoul was not to be tampered with. Thus, it evolved inWestern society that behavioral abnormalities were notavailable for study, and, in addition, mental illness orphysical symptoms in the absence of pathology wereconsidered second class: less legitimate than structuraldisease and even the United States, Benjamin Rush, a prominentphysician in the 18th century, sought to integrate psycho-logical and medical knowledge in the diagnosis and treat-ment of medical illness. However, after his death in 1813,psychiatry was separated from medical practice and mentalillness remained unstudied in the asylums. Later in the1800s, Louis Pasteur s discovery of microorganisms andRobert Koch s development of the germ theory of diseasefurther moved medicine in the direction of biologic reduc-tionism, in which diagnosis was related to specific etiologicagents.

10 However, in recent years (eg, with tuberculosis andacquired immune deficiency syndrome) we now know thatinfectious agents are conditional factors in disease etiology;host resistance and the social environment also contributeto the clinical expression of the of limited technology, explanatory models ofillness and disease through the 19th century developed fromnatural observations, which then were interpreted in terms ofetiology. However, an important advance occurred in 1833with William Beaumont s studies of Alexis St. Martin, a voya-geur who developed a traumatic gastricfistula from a gunshotinjury, thus allowing direct observation of gastric mucosalcolor and secretion. Beaumont s studies systematically re-ported the association of emotions such as anger and fear withgastric mucosal morphology and function, and was an earlypsychophysiological investigation of the human GI 2016 Functional GI and Rome IV 1263 Functional GI OVERVIEWE arly to Mid-20th Century: Observations ofGut and Brain Behavior (1900 1959)Beaumont set the stage for further investigations of theeffects of emotion on Gastrointestinal function.