Rome IV Diagnostic Criteria for Opioid-Induced Constipation

Rome IV Opioid-Induced Constipation

New or worsening constipation when initiating, changing, or increasing opioid therapy

Straining >25% of defecations

Lumpy or hard stools (Bristol 1-2) >25% of defecations

Sensation of incomplete evacuation >25% of defecations

Sensation of anorectal obstruction/blockage >25% of defecations

Manual maneuvers to facilitate >25% of defecations

<3 spontaneous bowel movements per week

Rome IV Assessment: Negative

Criteria Not Met

Criteria for opioid-induced constipation are not met.

Official Rome IV criteria for the diagnosis of opioid-induced constipation.

Why Use

To establish a diagnosis of opioid induced constipation. Establishing this diagnosis can help guide management of constipation symptoms. To help guide conversations with patients regarding etiology of constipation symptoms.

When to Use

Use in patients with symptoms suggestive of constipation in the setting of initiation of, changes to or increasing opioid therapy. This diagnosis should be made after a complete history, physical examination and limited diagnostic tests are performed.

Formula

To fulfill the Rome IV criteria for opioid-induced constipation, patient must have the following: New, or worsening, symptoms of constipation when initiating, changing, or increasing opioid therapy that must include ≥2 of the following: Straining during more than one-fourth (25%) of defecations. Lumpy or hard stools ( Bristol Stool Form Scale 1-2) more than one-fourth (25%) of defecations. Sensation of incomplete evacuation more than one-fourth (25%) of defecations. Sensation of anorectal obstruction/blockage more than one-fourth (25%) of defecations. Manual maneuvers to facilitate more than one-fourth (25%) of defecations (e.g. digital evacuation or support of the pelvic floor). <3 spontaneous bowel movements per week. Loose stools are rarely present without the use of laxatives.

Pearls / Pitfalls

Opioid induced constipation should be considered in patients with new onset constipation in the setting of starting opioids Opioid induced constipation can overlap with or exacerbate functional constipation (i.e., opioid associated constipation). If clinically indicated, simple laboratory tests (e.g. CBC, complete metabolic profile, serum calcium and thyroid-stimulating hormone) are reasonable to obtain. Some patients with opioid induced constipation may experience overflow diarrhea or incontinence related to significant constipation. An abdominal x-ray (KUB) can identify fecal impaction and the level and degree of stool burden. Consider narcotic bowel syndrome when patients on opioids get increasing abdominal pain. Secondary causes of constipation can occur in patients taking opioids and thus taking a history is necessary to determine if any red flag symptoms are present. Bowel habits while taking opioids should be compared to baseline bowel habits prior to initiation of opioids. Use the Bristol Stool Form Scale to determine stool form. It is important that patients look at both the pictures and the text.

Management

Management of opioid induced constipation is often similar to management of functional constipation. Treatment may include: Adequate dietary fiber intake and supplementation. Osmotic laxatives (e.g. PEG-3350, lactulose). Peripherally acting μ-opioid receptor antagonists (PAMORA) (e.g. naloxegol). Lubiprostone. Other secretagogues (e.g. linaclotide, plecanatide) may be considered. Stimulant laxatives (e.g. bisacodyl, senna) as a rescue medication. 5-HT 4 receptor agonist (e.g. prucalopride).

Critical Actions

This calculator should only be used in patients where a secondary cause of constipation other than opioid use (e.g. mechanical obstruction, systemic illness, medications) is not suspected based on clinical history, physical exam and initial work-up.

Advice

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