I can never remember the Rome criteria, so it came as something of a relief to know that they haven’t actually been validated for accuracy of diagnosis (what’s more, they’ve been updated anyway and now differ slightly from the ones I was trying to remember). The Manning criteria have, but, in practice, it seems to be more a case of looking at patterns – longstanding symptoms with no red flags aren’t likely to be due to anything serious.
The additional symptoms in the current Rome criteria (two out of three required) are:
- Pain/discomfort onset associated with change in stool frequency
- Pain/discomfort onset associated with change in stool form
- Pain/discomfort improves with defaecation
The Manning criteria, as well as the above, have:
- Passage of mucus per rectum
- Feeling of incomplete emptying
- Reported visible abdominal distension
(any of those symptoms for any length of time, which sounds rather vague to me)
Alarm symptoms to consider:
- Age >50 with no previous colonic screening
- Recent onset of/change in symptoms
- Weight loss
- Rectal bleeding (overt, or positive FOB)
- Abdominal mass
- Iron-deficiency anaemia
The things to avoid in diet, it seems, are FODMAPs – Fermentable Oligosaccharides, Disaccharides, Monosaccharides, And Polyols. Since foods containing these substances include most lactose-containing foods as well as several green vegetables and some fruits, this could be the unifying factor that explains why exclusion diets for those items have previously proved successful. Low-FODMAP diets are associated with decreased abdominal pain/discomfort, flatus, & bloating.
Gluten avoidence may also help symptoms, even in patients who screen negative for coeliac disease.
Medical treatments: Tailor to either predominant stool form or most troublesome symptom.
- Peppermint oil (lower NNT than for antispasmodics, and adverse events much less common)
- Antispasmodics. I normally use hyoscine – other recommended antispasmodics are otilonium, cimetropium, pinaverium, and dicycloverine.
- Probiotics – some benefit for abdo pain – not clear which ones are helpful, but possibly bifidobacteria
- Tricyclics – 2nd-line
- Soluble fibre supplement (ispaghula) +/- osmotic laxative
- Probiotics – possibly helpful, although the best that could be said was that there was a trend towards benefit in a meta-analysis
- Rifaximin – non-absorbable oral antibiotic which has been shown in an RCT to improve symptoms, including bloating, at 12 week follow-up after a 2-week course, with no increase in C. diff risk.
Psychological therapies have not been found to be effective.