This page listing new brain-gut axis disorders under Rome IV is under construction
"Many of the symptoms characteristic of the functional gastrointestinal disorders (FGID) are consistent with dysfunction of the motor and/or sensory apparatus of the digestive tract. Those aspects of sensorimotor dysfunction most relevant to the FGID include alterations in: gut contractile activity; myoelectrical activity; tone and compliance; and transit, as well as an enhanced sensitivity to distension, in each region of the gastrointestinal tract. Assessment of these phenomena involves a number of techniques, some well established and others requiring further validation. Using such techniques, researchers have reported a wide range of alterations in sensory and in motor function in the FGID. Importantly, however, relationships between such dysfunction and symptoms have been relatively weak, and so the clinical relevance of the former remains unclear. Moreover, the proportions of patients in the various symptom subgroups who display dysfunction, and the extent and severity of their symptoms, require better characterization. On a positive note, progress is occurring on several fronts, especially in relation to functional dyspepsia and irritable bowel syndrome, and based on the data gathered to date, a number of areas where further advances are required can be highlighted... "John Kellow et al.
Oesophagogastroduodenal disorders
https://www-sciencedirect-com.wwwproxy1.library.unsw.edu.au/science/article/pii/S0016508516001785:
Figure 1. The role of the brain–gut axis in mediating esophageal symptoms. Gut luminal and mucosal injury can sensitize visceral afferents causing allodynia or hyperalgesia. Psychological and cognitive factors such as hypervigilance participate in heightened pain perception. Both centrally and peripherally directed treatments can be helpful in management.
Functional chest pain
1.Retrosternal chest pain or discomfort; cardiac causes should be ruled out.
2.No associated esophageal symptoms (heartburn and dysphagia).
3. No evidence that gastroesophageal reflux (2 weeks bd PPI or pH study), or eosinophilic esophagitis (oesophageal biopsies) are cause of symptom.
4. Absence of major esophageal motor disorders (manometry: achalasia/EGJ outflow obstruction, diffuse oesophageal spasm, jackhammer oesophagus, absent peristalsis).
Figure 2. The interplay between esophageal hypersensitivity and acid exposure in the reflux symptom spectrum. Symptoms in erosive esophagitis are dominated by abnormal acid exposure whereas symptoms in functional heartburn are dominated by hypersensitivity. Symptoms in NERD and reflux hypersensitivity are related to a combination of both acid exposure and hypersensitivity, with a shift reflecting a more pronounced effect of acid exposure along the NERD diagnostic spectrum and a more pronounced effect of esophageal hypersensitivity along the reflux hypersensitivity diagnostic spectrum.
functional heartburn
Criteria must be fulfilled for the past 3 months with symptom onset at least 6 months before diagnosis with a frequency of at least twice a week. Must include all of the following.
- 1.
-
Burning retrosternal discomfort or pain.
- 2.
-
No symptom relief despite optimal antisecretory therapy.
- 3.
-
Absence of evidence that gastroesophageal reflux (abnormal acid exposure and symptom reflux association) or EoE is the cause of symptoms.
- 4.
-
Absence of major esophageal motor disorders (achalasia/EGJ outflow obstruction, diffuse esophageal spasm, jackhammer esophagus, absent peristalsis).
reflux hypersensitivity
Criteria must be fulfilled for the past 3 months with symptom onset at least 6 months before diagnosis with a frequency of at least twice a week. Must include all of the following.
- 1.
-
Retrosternal symptoms including heartburn and chest pain.
- 2.
-
Normal endoscopy and absence of evidence that EoE is the cause for symptoms.
- 3.
-
Absence of major esophageal motor disorders (achalasia/EGJ outflow obstruction, diffuse esophageal spasm, jackhammer esophagus, absent peristalsis).
- 4.
- Evidence of triggering of symptoms by reflux events despite normal acid exposure on pH or pH–impedance monitoring (response to antisecretory therapy does not exclude the diagnosis).
globus
Criteria must be fulfilled for the past 3 months with symptom onset at least 6 months before diagnosis with a frequency of at least once a week. Must include all of the following.
- 1.
-
Persistent or intermittent, nonpainful, sensation of a lump or foreign body in the throat with no structural lesion identified on physical examination, laryngoscopy, or endoscopy.
- a.
-
Occurrence of the sensation between meals.
- b.
-
Absence of dysphagia or odynophagia.
- c.
-
Absence of a gastric inlet patch in the proximal esophagus (trial cap-assisted APC 60 W, 2 L/min).
- 2.
-
Absence of evidence that gastroesophageal reflux (PPI therapy for 4–8 weeks) or EoE is the cause of the symptom.
- 3.
- Absence of major esophageal motor disorders (achalasia/EGJ outflow obstruction, diffuse esophageal spasm, jackhammer esophagus, absent peristalsis).
functional dysphagia
Criteria must be fulfilled for the past 3 months with symptom onset at least 6 months before diagnosis with a frequency of at least once a week. Must include all of the following.
- 1.
-
Sense of solid and/or liquid foods sticking, lodging, or passing abnormally through the esophagus.
- 2.
-
Absence of evidence that esophageal mucosal or structural abnormality is the cause of the symptom.
- 3.
-
Absence of evidence that gastroesophageal reflux or EoE is the cause of the symptom.
- 4.
- Absence of major esophageal motor disorders (achalasia/EGJ outflow obstruction, diffuse esophageal spasm, jackhammer esophagus, absent peristalsis).
https://www-sciencedirect-com.wwwproxy1.library.unsw.edu.au/science/article/pii/S0016508516001785
Impaired gastric motility stems from diminished phase III contractions of the migrating motor complex (MMC) in the gastric antrum and the subsequent generation of dyskinetic contractions through the small bowel. Neuroendocrine abnormalities contribute including higher concentrations of motility‐suppressing hormones (cholecystokinin, glucagon‐like peptide‐1, peptide YY, and amylin) and lower concentrations of motility‐stimulating hormones (acyl‐ghrelin and motilin).
Functional Dyspepsia
Diagnostic criteria
1. One or more of the following:
a.Bothersome postprandial fullness
b. Bothersome early satiation
c. Bothersome epigastric pain
d. Bothersome epigastric burning
AND
2. No evidence of structural disease (including at upper endoscopy) that is likely to explain the symptoms
a Must fulfill criteria for B1a. PDS and/or B1b. EPS.
b Criteria fulfilled for the last 3 months with symptom onset at least 6 months before diagnosis.
B1a. Postprandial Distress Syndrome
Must include one or both of the following at least 3 days per week:
1. Bothersome postprandial fullness (ie, severe enough to impact on usual activities)
2. Bothersome early satiation (ie, severe enough to prevent finishing a regular-size meal)
No evidence of organic, systemic, or metabolic disease that is likely to explain the symptoms on routine investigations (including at upper endoscopy)
a Criteria fulfilled for the last 3 months with symptom onset at least 6 months before diagnosis.
Supportive remarks
• Postprandial epigastric pain or burning, epigastric bloating, excessive belching, and nausea can also be present
• Vomiting warrants consideration of another disorder
• Heartburn is not a dyspeptic symptom but may often coexist
• Symptoms that are relieved by evacuation of feces or gas should generally not be considered as part of dyspepsia
Other individual digestive symptoms or groups of symptoms, eg, from gastroesophageal reflux disease and the irritable bowel syndrome may coexist with PDS
B1b. Epigastric Pain Syndrome
Must include at least 1 of the following symptoms at least 1 day a week:
1. Bothersome epigastric pain (ie, severe enough to impact on usual activities)
AND/OR
2. Bothersome epigastric burning (ie, severe enough to impact on usual activities)
No evidence of organic, systemic, or metabolic disease that is likely to explain the symptoms on routine investigations (including at upper endoscopy).
a Criteria fulfilled for the last 3 months with symptom onset at least 6 months before diagnosis
Supportive remarks
1. Pain may be induced by ingestion of a meal, relieved by ingestion of a meal, or may occur while fasting
2. Postprandial epigastric bloating, belching, and nausea can also be present
3. Persistent vomiting likely suggests another disorder
4. Heartburn is not a dyspeptic symptom but may often coexist
5. The pain does not fulfill biliary pain criteria
6. Symptoms that are relieved by evacuation of feces or gas generally should not be considered as part of dyspepsia
Other digestive symptoms (such as from gastroesophageal reflux disease and the irritable bowel syndrome) may coexist with EPS
Belching Disorders
Must include all of the following:
Bothersome (ie, severe enough to impact on usual activities) belching from the esophagus or stomach more than 3 days a week
B2a: Excessive supragastric belching (from esophagus)
B2b: Excessive gastric belching (from stomach).
Supportive remarks
- •
-
Supragastric belching is supported by observing frequent, repetitive belching
- •
-
Gastric belching has no established clinical correlate
- •
-
Objective intraluminal impedance measurement can be used to distinguish supragastric from gastric belching.
aCriteria fulfilled for the last 3 months with symptom onset at least 6 months before diagnosis.
Nausea and Vomiting Disorders
B3a: Chronic Nausea and Vomiting Syndrome (CNVS)
Must include all of the following:
- 1.
-
Bothersome (ie, severe enough to impact on usual activities) nausea, occurring at least 1 day per week and/or 1 or more vomiting episodes per week
- 2.
-
Self-induced vomiting, eating disorders, regurgitation, or rumination are excluded
- 3.
-
No evidence of organic, systemic, or metabolic diseases that is likely to explain the symptoms on routine investigations (including at upper endoscopy).
aCriteria fulfilled for the last 3 months with symptom onset at least 6 months before diagnosis
B3b: Cyclic Vomiting Syndrome (CVS)
Must include all of the following:
Stereotypical episodes of vomiting regarding onset (acute) and duration (less than 1 week)
- 1.
-
At least e discrete episodes in the prior year and 2 episodes in the past 6 months, occurring at least 1 week apart
- 2.
-
Absence of vomiting between episodes, but other milder symptoms can be present between cycles
Supportive remarks:
- •
-
History or family history of migraine headaches
B3c: Cannabinoid Hyperemesis Syndrome (CHS)
Diagnostic criteriaa
Must include all of the following:
- 1.
-
Stereotypical episodic vomiting resembling cyclic vomiting syndrome (CVS) in terms of onset, duration, and frequency
- 2.
-
Presentation after prolonged excessive cannabis use
- 3.
-
Relief of vomiting episodes by sustained cessation of cannabis use
aCriteria fulfilled for the last 3 months with symptom onset at least 6 months before diagnosis
Supportive remarks:
- •
- May be associated with pathologic bathing behavior (prolonged hot baths or showers).
Rumination Syndrome
Must include all of the following:
- 1.
-
Persistent or recurrent regurgitation of recently ingested food into the mouth with subsequent spitting or remastication and swallowing
- 2.
-
Regurgitation is not preceded by retching.
aCriteria fulfilled for the last 3 months with symptom onset at least 6 months before diagnosis.
Supportive remarks:
- •
-
Effortless regurgitation events are usually not preceded by nausea
- •
-
Regurgitant contains recognizable food that might have a pleasant taste
- •
- The process tends to cease when the regurgitated material becomes acidic.
nausea=unpleasant feeling of unease with the sensation that vomiting might occur, frequently preceded by feelings of anorexia and often accompanied by objective autonomic symptoms of pallor, hypersalivation, diaphoresis, and tachycardia
vomiting=forceful ejection of gastric contents from the mouth with contraction of chest, abdominal and diaphragm muscles
retching=Spasmodic respiratory movements against a closed glottis with contractions of the abdominal musculature without expulsion of any gastric contents, referred to as “dry heaves”
regurgitation= effortless and involuntary movement of gastric contents into the mouth without abdominal wall contractions. Nausea and autonomic features rare.
rumination=voluntary and effortlessly bring up recently ingested food from the stomach into the mouth, where it is often then chewed again and re-swallowed. nausea and autonomic features rare.
Common causes of chronic nausea/vomiting
Gastroparesis Functional dyspepsia Cyclic vomiting syndrome (CVS) Cannabinoid hyperemesis syndrome (CHS) Chronic nausea and vomiting syndrome (CNVS) Anatomic causes (gastric outlet obstruction, intermittent partial bowel obstruction, extrinsic compression of the GI tract, stenosis from ischemia, radiation or Crohn’s disease) Chronic pancreatitis Hepatobiliary disorders (acute and chronic hepatitis; infiltrative disorders; partial biliary obstruction) Endocrine disorders (diabetes, hyperglycemia) Chronic intestinal pseudo-obstruction (primary or secondary) Vascular disorders (median arcuate ligament syndrome, SMA syndrome, chronic ischemia) Connective tissue disorders (scleroderma, SLE) Renal insufficiency Vestibular disorders (labyrinthitis, Meniere’s disease, motion sickness, chronic otitis media) Esophageal disorders (achalasia, Zenker’s diverticulum) Medications (opioids, antibiotics, antiarrhythmics, anticonvulsants) Neurologic disorders (Parkinson’s disease, seizure disorders, migraine headaches) Cardiac disorders (ischemia, congestive heart failure) Eating disorders (anorexia, bulimia) Psychogenic causes (anxiety, depression, conversion disorder, learned behaviors) Miscellaneous (alcohol abuse, post-vagotomy) Uncommon causes of chronic nausea/vomiting
Endocrine disorders (hyperthyroidism, Addison’s disease, hyponatremia, hyperparathyroidism, hypercalcemia) Paraneoplastic syndromes Radiation-induced CNS disorders (aneurysm, tumor, hydrocephalus, meningitis, pseudotumor cerebri) Nervous system disorders (severe neuropathy, demyelinating disorders, autonomic nervous system disorders) Renal and urologic disorders (nephrolithiasis, obstruction) Severe constipation Retroperitoneal and mesenteric pathology Inflammatory bowel disease (Crohn’s disease, ulcerative colitis) Miscellaneous (acute intermittent porphyria, Familial Mediterranean Fever, angioedema, glaucoma, toxins/poisons, mitochondrial disorders, ion channel disorders, food allergies, and intolerances)
Vomiting or regurgitation Forceful expulsion Vomiting from the stomach Passive regurgitation Esophageal disorders such as GERD, achalasia, and rumination syndrome Initial onset, progression, and duration of symptoms Insidious onset of nausea: Gastroparesis, a medication-related side effect, metabolic disorders, pregnancy, gastroesophageal reflux disease Description of the vomitus Regurgitation of undigested food Esophageal disorders—achalasia, esophageal stricture, Zenker’s diverticulum Vomiting of partially digested food several hours after a meal Gastroparesis or gastric outlet obstruction Bilious vomiting Small bowel obstruction Feculent or putrid odor to vomitus Bacterial degradation of stagnant intestinal contents, a feature of intestinal obstruction Timing and description of vomiting Vomiting in am before breakfast Pregnancy, uremia, alcohol ingestion, increased intracranial pressure Projectile vomiting, without nausea Increased intracranial pressure Nausea and vomiting an hour after meal Gastroparesis or gastric outlet obstruction Vomiting during or soon after meal Rumination, anorexia nervosa or bulimia Episodes of severe unrelenting vomiting Cyclic vomiting syndrome, Cannabinoid Hyperemesis Conditioned vomiting The original symptoms of “organic” origin are reinforced by short-term benefits of initial therapy, and the now chronic symptoms represent a learned behavior Associated symptoms Early satiety, postprandial abdominal fullness/bloating Gastroparesis Abdominal pain Biliary or pancreatic disorder Pain is prominent, severe, and colicky; may improve after vomiting Small bowel obstruction Weight loss Malignancy, gastroparesis and gastric outlet obstruction CNS symptoms—headache, vertigo, focal neurologic deficits Central cause of nausea and vomiting Vomiting as the only manifestation of a brainstem tumor is rare
Gallbladder and Sphincter of Oddi Disorders
Diagnostic Criteria for:
E1. Biliary Pain
Pain located in the epigastrium and/or right upper
quadrant and all of the following:
1. Builds up to a steady level and lasting 30 minutes
or longer
2. Occurring at different intervals (not daily)
3. Severe enough to interrupt daily activities or lead
to an emergency department visit
4. Not significantly (<20%) related to bowel
movements
5. Not significantly (<20%) relieved by postural
change or acid suppression
Supportive Criteria
The pain may be associated with:
1. Nausea and vomiting
2. Radiation to the back and/or right infrasubscapular
region
3. Waking from sleep
E1a. Functional Gallbladder Disorder
1. Biliary pain
2. Absence of gallstones or other structural pathology
Supportive Criteria
1. Low ejection fraction on gallbladder scintigraphy
2. Normal liver enzymes, conjugated bilirubin, and
amylase/lipase
Consider: repeat US, EUS, gastroscopy, oesophageal manometry or gastric emptying or transit studies to rule out peptic ulcer disease, subtle chronic pancreatitis, fatty liver disease, or musculoskeletal syndromes.
E1b. Functional Biliary Sphincter of Oddi Disorder
1. Biliary pain
2. Elevated liver enzymes or dilated bile duct, but
not both
3. Absence of bile duct stones or other structural
abnormalities
Supportive Criteria
1. Normal amylase/lipase
2. Abnormal sphincter of Oddi manometry
3. Hepatobiliary scintigraphy
Consider: exclude organic disease in post cholecystectomy pain including retained
stones or partial GB; postoperative complications (such as a bile leak or duct stricture); other intra-abdominal disorders, such as pancreatitis, fatty liver disease, peptic ulceration, functional dyspepsia and irritable bowel syndrome; musculoskeletal disorders; and other rare conditions. Tests including liver and pancreas biochemistry, gastroscopy, and abdominal imaging (ultrasound/CT to MRCP or EUS).
E2. Pancreatic Sphincter of Oddi Disorder
All of the following:
1. Documented recurrent episodes of pancreatitis
(typical pain with amylase or lipase >3 times
normal and/or imaging evidence of acute
pancreatitis)
2. Other etiologies of pancreatitis excluded
3. Negative endoscopic ultrasound
4. Abnormal sphincter manometry
Bowel Disorders
Irritable Bowel Syndrome
Recurrent abdominal pain, on average, at least 1 day per
week in the last 3 months, associated with 2 or more of
the following criteria:
1. Related to defecation
2. Associated with a change in frequency of stool
3. Associated with a change in form (appearance) of
stool
a
Criteria fulfilled for the last 3 months with symptom
onset at least 6 months before diagnosis.
Diagnostic criteria for IBS subtypes (Figure 11-11,
FM 12)
Predominant bowel habits are based on stool form on
days with at least one abnormal bowel movement.a
IBS with predominant constipation: More than onefourth
(25%) of bowel movements with Bristol stool
form types 1 or 2 and less than one-fourth (25%) of
bowel movements with Bristol stool form types 6 or 7.
Alternative for epidemiology or clinical practice: Patient
reports that abnormal bowel movements are usually
constipation (like type 1 or 2 in the picture of Bristol
Stool Form Scale (BSFS), see Figure 2A).
IBS with predominant diarrhea (IBS-D): more than onefourth
(25%) of bowel movements with Bristol stool
form types 6 or 7 and less than one-fourth (25%) of
bowel movements with Bristol stool form types 1 or 2.
Alternative for epidemiology or clinical practice: Patient
reports that abnormal bowel movements are usually
diarrhea (like type 6 or 7 in the picture of BSFS, see
Figure 2A).
IBS with mixed bowel habits (IBS-M): more than onefourth
(25%) of bowel movements with Bristol stool
form types 1 or 2 and more than one-fourth (25%) of
bowel movements with Bristol stool form types 6 or 7.
Alternative for epidemiology or clinical practice: Patient
reports that abnormal bowel movements are usually
both constipation and diarrhea (more than one-fourth of
all the abnormal bowel movements were constipation
and more than one-fourth were diarrhea, using picture
of BSFS, see Figure 2A).
IBS unclassified (IBS-U): Patients who meet diagnostic
criteria for IBS but whose bowel habits cannot be
accurately categorized into 1 of the 3 groups above
should be categorized as having IBS unclassified.
For clinical trials, subtyping based on at least 2 weeks of
daily diary data is recommended, using the “25% rule.”
a
IBS subtypes related to bowel habit abnormalities (IBSC,
IBS-D, and IBS-M) can only be confidently established
when the patient is evaluated off medications used to
treat bowel habit abnormalities.
Functional Constipation
1. Must include 2 or more of the following:b
a. Straining during more than one-fourth (25%)
of defecations
b. Lumpy or hard stools (BSFS 12) more than
one-fourth (25%) of defecations
c. Sensation of incomplete evacuation more than
one-fourth (25%) of defecations
d. Sensation of anorectal obstruction/blockage
more than one-fourth (25%) of defecations
e. Manual maneuvers to facilitate more than one
fourth (25%) of defecations (eg, digital evacuation,
support of the pelvic floor)
f. Fewer than 3 spontaneous bowel movements
per week
2. Loose stools are rarely present without the use of
laxatives
3. Insufficient criteria for irritable bowel syndrome
a
Criteria fulfilled for the last 3 months with symptom
onset at least 6 months prior to diagnosis.
b
For research studies, patients meeting criteria for OIC
should not be given a diagnosis of FC because it is
difficult to distinguish between opioid side effects and
other causes of constipation. However, clinicians recognize
that these 2 conditions might overlap.
Functional Diarrhea
Loose or watery stools, without predominant abdominal
pain or bothersome bloating, occurring in >25% of
stools.b
a
Criterion fulfilled for the last 3 months with symptom
onset at least 6 months before diagnosis
b
Patients meeting criteria for diarrhea-predominant IBS
should be excluded
Functional Abdominal
Bloating/Distension
Must include both of the following:
1. Recurrent bloating and/or distention occurring,
on average, at least 1 day per week; abdominal
bloating and/or distention predominates over
other symptoms.b
2. There are insufficient criteria for a diagnosis of
irritable bowel syndrome, functional constipation,
functional diarrhea, or postprandial distress
syndrome.
a Criteria fulfilled for the last 3 months with symptom
onset at least 6 months prior to diagnosis.
b Mild pain related to bloating may be present as well as
minor bowel movement abnormalities.
Unspecified Functional
Bowel Disorder
Bowel symptoms not attributable to an organic etiology
that do not meet criteria for IBS or functional constipation,
diarrhea, or abdominal bloating/distention
disorders.
a
Criterion fulfilled for the last 3 months with symptom
onset at least 6 months before diagnosis
Opioid-Induced Constipation
1. New, or worsening, symptoms of constipation
when initiating, changing, or increasing opioid
therapy that must include 2 or more of the
following:
a. Straining during more than one-fourth (25%)
of defecations
b. Lumpy or hard stools (BSFS 12) more than
one-fourth (25%) of defecations
c. Sensation of incomplete evacuation more than
one-fourth (25%) of defecations
d. Sensation of anorectal obstruction/blockage
more than one-fourth (25%) of defecations
e. Manual maneuvers to facilitate more than onefourth
(25%) of defecations (eg, digital evacuation,
support of the pelvic floor)
f. Fewer than three spontaneous bowel movements
per week
2. Loose stools are rarely present without the use of
laxatives
Anorectal disorders
Fecal Incontinence
1. Recurrent uncontrolled passage of fecal material
in an individual with a developmental age of at
least 4 years
a
Criteria fulfilled for the last 3 months. For research
studies, consider onset of symptoms for at least 6
months previously with 24 episodes of FI over 4
weeks.
Common Causes of Fecal Incontinence
Anal sphincter weakness
Traumatic: obstetric, surgical (eg, hemorrhoidectomy, internal
sphincterotomy, fistulectomy)
Nontraumatic: scleroderma, idiopathic internal sphincter
degeneration
Neuropathy
Peripheral (eg, pudendal) or generalized (eg, diabetes mellitus)
Pelvic floor disorders
Rectal prolapse, descending perineum syndrome
Disorders affecting rectal capacity and/or sensationa
Inflammatory conditions: radiation proctitis, Crohn’s disease,
ulcerative colitis
Anorectal surgery (pouch, anterior resection)
Rectal hyposensitivity
Rectal hypersensitivity
Central nervous system disorders
Dementia, stroke, brain tumors, multiple sclerosis, spinal cord
lesions
Psychiatric diseases, behavioral disorders
Bowel disturbances
Irritable bowel syndrome, post-cholecystectomy diarrhea
Constipation and fecal retention with overflow
a These conditions may also be associated with diarrhea
Functional Anorectal Pain
Levator Ani Syndrome.
Must include all of the following:
1. Chronic or recurrent rectal pain or aching
2. Episodes last 30 minutes or longer
3. Tenderness during traction on the puborectalis
4. Exclusion of other causes of rectal pain, such as
inflammatory bowel disease, intramuscular abscess
and fissure, thrombosed hemorrhoids,
prostatitis, coccygodynia, and major structural alterations
of the pelvic floor.
a
Criteria fulfilled for the last 3 months with symptom
onset at least 6 months before diagnosis.
F2b. Unspecified Functional Anorectal Pain
Symptom criteria for chronic levator ani syndrome but
no tenderness during posterior traction on the puborectalis muscle
r Proctalgia Fugax
Must include all of the following:
1. Recurrent episodes of pain localized to the rectum
and unrelated to defecation
2. Episodes last from seconds to minutes, with a
maximum duration of 30 minutes
3. There is no anorectal pain between episodes.
4. Exclusion of other causes of rectal pain, such as
inflammatory bowel disease, intramuscular abscess
and fissure, thrombosed hemorrhoids,
prostatitis, coccygodynia, and major structural alterations of the pelvic floor.
a For research purposes, criteria must be fulfilled for 3
months with symptom onset at least 6 months before
diagnosis.
Functional Defecation
Disorders
1. The patient must satisfy diagnostic criteria for
functional constipation and/or irritable bowel
syndrome with constipation
2. During repeated attempts to defecate, there must
be features of impaired evacuation, as demonstrated
by 2 of the following 3 tests:
a. Abnormal balloon expulsion test
b. Abnormal anorectal evacuation pattern with
manometry or anal surface EMG
c. Impaired rectal evacuation by imaging
Subcategories F3a and F3b apply to patients who satisfy
criteria for FDD
F3a. Inadequate Defecatory Propulsion
Inadequate propulsive forces as measured with
manometry with or without inappropriate contraction of
the anal sphincter and/or pelvic floor muscles
F3b. Dyssynergic Defecation
Inappropriate contraction of the pelvic floor as
measured with anal surface EMG or manometry
with adequate propulsive forces during attempted
defecation b
a Criteria fulfilled for the last 3 months with symptom
onset at least 6 months before diagnosis.
b These criteria are defined by age- and sex-appropriate
normal values for the technique.