Rome IV Diagnostic Criteria for Functional Diarrhea

Rome IV Functional Diarrhea

Loose/watery stools (Bristol 6-7) in >25% of bowel movements

Criteria for IBS are NOT met

Present for last 3 months with onset ≥6 months prior

Rome IV Assessment: Negative

Criteria Not Met

No criteria met for Rome IV functional diarrhea.

Official Rome IV criteria for the diagnosis of functional diarrhea.

Why Use

Used to diagnose functional diarrhea in the absence of secondary causes of diarrhea. Making a diagnosis will help guide the need for further work-up and management. Can be used to discuss signs and symptoms of functional diarrhea with patients.

When to Use

Patients presenting with chronic diarrhea for at least the past 6 months with no clear systemic cause of chronic diarrhea. The diagnosis of functional diarrhea should be made based on clinical history, physical examination, and diagnostic tests.

Formula

To fulfill the Rome IV criteria for functional diarrhea, patient must have the following (for 3 months prior with symptom onset ≥6 months ago): Loose or watery stools, without predominant abdominal pain or bothersome bloating, occurring in >25% of stools. Does not meet criteria for diarrhea-predominant IBS .

Pearls / Pitfalls

Diarrhea should be defined by stool form and not frequency. Use the Bristol Stool Form Scale to determine stool form. It is important that patients look at both the pictures and the text. Bristol Stool Form type 6 or 7 are considered diarrhea. Be sure to evaluate stool form when the patient is off medications that affect bowel habit. If abdominal pain is present in addition to diarrhea symptoms, a diagnosis of the diarrhea-predominant irritable bowel syndrome (IBS-D) should be considered. Biopsies of right and left colon to assess for microscopic colitis should be taken when a colonoscopy is performed. This should be done even if the colonic mucosa appears normal.

Management

Management of functional diarrhea may include: Diet modifications. Adequate dietary fiber intake and supplementation. Peripheral opioid agonists (e.g. loperamide). Bile acid binders (e.g. cholestyramine, colesevelam). Neuromodulators (e.g. tricyclic antidepressants). 5-HT3 antagonists (e.g. ondansetron, alosetron). Mixed opioid agonist/antagonist (e.g. eluxadoline). Antibiotics (e.g. rifaximin). Note that many of these treatment options have limited evidence in functional diarrhea specifically but are often used in, the related condition, diarrhea predominant irritable bowel syndrome (IBS-D) . 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 diarrhea is not suspected based on clinical history, physical exam and diagnostic testing.

Advice

If diagnosis not met (negative): Symptoms unlikely to be caused by functional diarrhea. Consider further assessment as clinically indicated. If meets diagnosis (positive): Likely diagnosis of functional diarrhea. Consider initiating treatment.