REFERENCES

1. Pope CE. A dynamic test of sphincter strength: Its applicationto the lower esophageal sphincter. Gastroenterology 1967;52:779–86.

2. Arndorfer RC, Stef JJ, Dodds WJ, et al. Improved infusionsystem for intraluminal esophageal manometry. Gastroenter-ology 1977;73:23–7.

3. Dent J. A new technique for continuous sphincter pressuremeasurement. Gastroenterology 1976;71:263–71.

4. Omari T, Bakewell M, Fraser R, et al. Intraluminalmicromanometry: An evaluation of the dynamic performanceof micro-extrusions and sleeve sensors. NeurogastroenterolMotil 1996;8:241–5.

5. Clouse RE, Staiano A, Alrakawi A, et al. Application oftopographic methods to clinical esophageal manometry. Am JGastroenterol 2000;95:2720–30.

6. Clouse RE, Staiano A, Alrakawi A. Development of a topo-graphic analysis system for manometric studies in the gastro-intestinal tract. Gastrointest Endosc 1998;48:395–401.

7. Traube M, Peterson J, Siskind BN, et al. “Segmental aperi-stalsis” of the esophagus: A cause of chest pain and dysphagia.Am J Gastroenterol 1988;83:1381–5.

8. Freidin N, Mittal R, Traube M, et al. Segmental high ampli-tude peristaltic contractions in the distal esophagus. Am JGastroenterol 1989;84:619–23.

9. Li M, Brasseur JG, Dodds WJ. Analyses of normal and ab-normal esophageal transport using computer simulations.Am J Physiol 1994;266:G525–G543.

10. Clouse RE, Staiano A, Bickston SJ, et al. Characteristics of thepropagating pressure wave in the esophagus. Dig Dis Sci1996;41:2369–76.

11. Staiano A, Clouse RE. The effects of cisapride on the topog-raphy of oesophageal peristalsis. Aliment Pharmacol Ther1996;10:875–82.

12. Edmundowicz SA, Clouse RE. Shortening of the esophagus inresponse to swallowing. Am J Physiol 1991;260:G512–6.

13. Massey BT, Dodds WJ, Hogan WJ, et al. Abnormal esopha-geal motility: An analysis of concurrent radiographic andmanometric findings. Gastroenterology 1991;101:344–54.

14. Clouse RE, Weinstock LB, Ferney DM. Accuracy of abbre-viated manometry in detecting esophageal motility abnormal-ities. Dig Dis Sci 1989;34:66–70.

15. Novais L, Dalton C, Richter J. Stationary vs mapping manom-etry in evaluating dysphagia. Dysphagia 1990;5:187–91.

Correspondence:Assoc. Prof. Richard H. Holloway, Departmentof Gastroenterology, Hepatology and General Medicine, RoyalAdelaide Hospital, North Terrace, Adelaide, SA, 5000.

Received July 11, 2000; accepted July 13, 2000.

Rome? Manning? Who Cares?In this issue of theAmerican Journal of Gastroenterology,Saitoet al. (1) present an important report concerning thetwo most often used definitions of the irritable bowel syn-drome (IBS): the older but still widely used Manning criteria(2), and the Rome I criteria from 1989 (3). The latterdefinition has recently been revised, called Rome II (4).Saito et al.’s publication is of crucial importance: IBS isvery common (see Table 6 in Saitoet al.’s article), and it isexpensive to society (5); and, as researchers present data

with either definition, it is important to be able to comparethe results of different authors.

The confusion with two definitions in the arena is madeeven worse by the fact that different cut-off levels can beused for both definitions, as discussed by Saitoet al., with,of course, lower prevalence with higher cut-offs. Nobodyknows which cut-off is clinically applicable in either defi-nition. However, the prevalence of IBS with the Manningcriteria is consistently higher than with the Rome criteria.Despite this, Saitoet al. show an acceptable agreement inidentifying subjects with IBS using either definition, withbothk statistics and “overall agreement”. The same findingsconcerning both prevalence rates and diagnostic agreementhave been reported from population-based surveys before(6–8). It can be argued that the Manning criteria are moresensitive in finding cases than the Rome I criteria. The lowersensitivity of the Rome I criteria has recently been focusedon in an abstract at the Digestive Diseases Week 2000 (9),where Saitoet al. also showed that the new Rome II criteriagive even lower prevalence rates than Rome I in commu-nity-based samples (10). Also, Hahnet al. (6) postulatedthat both the Manning criteria and the Rome I definition ofIBS underestimate the true number of sufferers.

So, what is the truth? The Manning criteria (2) wereoriginally created and validated in a secondary care patientpopulation, and the results from Manninget al. have beenconfirmed (11), showing that the sensitivity is acceptablebut the sensitivity is poor: this is the reason why cliniciansmust exclude organic disorders by including “alarm” symp-toms and investigations based on their “intuition.” TheRome criteria are based on factor analysis of population-based data (12) and have been shown to have reasonableaccuracy when combined with alarm symptoms and signs insecondary care patients (13), except for lactose intolerance(14), in secondary care. To my knowledge, no investigatorhas tried to validate the accuracy of the two definitions,including intestinal investigations, in a primary care settingor in a population sample. This is necessary as secondarycare IBS patients represent only a subset of all sufferers (15)and most probably are heavily biased by health care-seekingbehavior (16). It is also a huge task!

Who uses the current definitions? It is the researcher, inboth epidemiological studies, trying to approach the un-selected population by mailed questionnaires, and in face-to-face consultations with either patients or subjects in astudy. In these situations, there is time to use extensivequestionnaires with several pages of questions.

What other sources of information concerning diseasesare available? One increasingly used source is computerizedmedical records, which also can “force” the doctor to setdiagnoses at each consultation or telephone contact. A vastmajority of those people with IBS symptoms consult ingeneral practice (15). In Sweden today, as in many othercountries, most primary health care centers are computer-ized (17), and in hospitals this process is accelerating. Thisgives us access to very important information about the IBS

2679AJG – October, 2000 Editorials

patients, as clinical information can now easily be extractedfrom the medical records.

However, how is the IBS diagnosis made in clinicalpractice? If data from research and everyday clinical workare to be compared, diagnoses in research and reality mustbe comparable or, ideally, identical. Thompsonet al. (18)showed that only nine of 55 general practitioners undersurvey have heard of the Manning criteria, and just one ofthem had heard of the Rome definition. None of them usedthese criteria in their practice. Despite this they referred only14% of the IBS patients for a second opinion. In anotherstudy from the same group (15), 48% of the patients thatfulfilled the Rome I and/or Manning criteria were not clas-sified as such by the general practitioners, although half ofthese received a related functional gastrointestinal diagno-sis. When I was invited to write this editorial, I asked the136 general practitioners in the County of Uppsala, Sweden,whether they had ever heard of the Rome definition or theManning criteria, and whether they used them. The doctorsare specialized in family medicine and most of them expe-rienced. Thirty-six answered promptly; of those, two hadheard of Manning’s criteria but never used it, and one hadheard of the Rome definition, and thought he used it! Theywere also asked how they diagnosed IBS. The overwhelm-ing majority mentioned abdominal pain and concomitant“unspecified” bowel problems, taking alarm symptoms intoconsideration, and ordered investigations when needed. Theresponse rate is low, but most probably the nonrespondersare not more familiar with the terminology!

So how come this lack of definition works in practice?Well, one reason is that the Rome definition and the Man-ning criteria are too complicated to use in the busy clinicalworkday. Most patients with functional abdominal disordersare treated in primary health care (15), where an individualdoctor sees up to 150 patients per week (19), and gastroin-testinal complaints constitute only about 5% of all cases inprimary health care (20). Not only gastroenterologists butmany other specialists have presented complicated and,thereby, unusable algorithms. Many of the conditions en-countered are polysymptomatic, and thus diagnosis is oftenbased on clinical impression rather than applying definitionsdeveloped for the purposes of research (18). The situation inmost gastroenterologists’ practices not engaged in research,where up to half of the patients present with functionaldisorders (21), is probably similar. Another reason might bethat the definitionsper seare not applicable in a generalpractice setting, as they are not validated in that setting, andthat therefore the general practitioner has to treat the patientsaccording to his or her enormous experience combined with“unstructured” knowledge.

Attempts have been made to simplify the IBS definition.Kruis et al. (22) designed a scoring system with only pain,flatulence, bowel irregularity, and alternating constipationand diarrhea as mandatory symptoms, combined with symp-tom duration and negative laboratory tests. The Kruis scor-ing system has been found to be equivalent to the Manning

criteria in identifying IBS and excluding organic gastroin-testinal disease (23). Also, our group has shown that asimple definition with only abdominal pain or discomfortcombined with constipation or diarrhea, or alternating con-stipation or diarrhea, gives the same prevalence rates as theRome I definition, and slightly lower than the Manningcriteria. The general agreement between this simple defini-tion and the Rome criteria was very good (k 0.85, generalagreement 96%), and somewhat lower than that with theManning criteria. This simple definition can be criticized fornot separating symptoms of stool consistency and defeca-tion frequency, and defecation problems. We (8, 24) andothers (25) have shown, however, that these different stooland defecation entities in layman’s terms are understood asconstipation or diarrhea. The definition has been validated ina general population sample (26), but not with any controlinvestigations! It also seems to be consistent with the waygeneral practitioners think.

So who cares about Rome and Manning? Certainly notthose doctors looking after most of the patients! As newclinical data become available because of computerizationand as new IBS drugs are introduced on the market, we needdiagnostic criteria for IBS that are validated in all settingsand are applicable not only in research but also in clinicalpractice. The most important statement in the paper by Saitoet al. is, consequently, the last one in the paper: further studiesare needed to delineate the optimal criteria needed to iden-tify and diagnose individuals with IBS in the community!

Lars Agreus, M.D., Ph.D.Family Medicine Stockholm

Karolinska InstitutetStockholm, Sweden

Primary Health Care CentreHallstavik, Sweden

REFERENCES

1. Saito YA, Locke III GR, Talley NJ, et al. A comparison of theRome and Manning criteria for case identification in epi-dermiological investigations of irritable bowel syndrome. AmJ Gastroenterol 2000;95:2816–24.

2. Manning AP, Thompson WG, Heaton KW, et al. Towardspositive diagnosis of the irritable bowel. Br Med J 1978;2:653–4.

3. Thompson WG, Dotevall G, Drossman DA, et al. Irritablebowel syndrome: Guidelines for the diagnoses. GastroenterolInt 1989;2:92–5.

4. Thompson WG, Longstreth GF, Drossman DA, et al. Func-tional bowel disorders and functional abdominal pain. Gut1999;45(suppl II):1143–7.

5. Talley NJ, Gabriel SE, Harmsen WS, et al. Medical costs incommunity subjects with irritable bowel syndrome. Gastroen-terology 1995;109:1736–41.

6. Hahn BA, Saunders WB, Maier WC. Differences betweenindividuals with self-reported irritable bowel syndrome (IBS)and IBS-like symptoms. Dig Dis Sci 1997;42:2585–90.

7. Kay L, Jørgensen T, Lanng C. Irritable bowel syndrome:Which definitions are consistent? J Intern Med 1998;244:489–94.

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8. Agreus L, Talley N, Sva¨rdsudd K, et al. Identifying dyspepsiaand irritable bowel syndrome: The value of pain or discomfort,and bowel habit descriptors. Scand J Gastroenterol 2000;35:142–51.

9. Bommelaer G, Dorval E, Denis P, et al. Prevalence of irritablebowel syndrome according to the Rome criteria in the Frenchpopulation. Gastroenterology 2000;118 (suppl 2):A–760.

10. Saito A, Locke GR, Talley NJ, et al. The effect of newdiagnostic criteria for irritable bowel syndrome on communityprevalence estimates. Gastroenterology 2000;118(suppl 2):A–402.

11. Talley NJ, Phillips SF, Melton LJ, et al. Diagnostic value ofthe Manning criteria in irritable bowel syndrome. Gut 1990;31:77–81.

12. Whitehead WE. Patient subgroups in irritable bowel syndromethat can be defined by symptom evaluation and physical ex-amination. Am J Med 1999;107:33S–40S.

13. Vanner SJ, Depew WT, Paterson WG, et al. Predictive valueof the Rome criteria for diagnosing the irritable bowel syn-drome [see comments]. Am J Gastroenterol 1999;94:2912–7.

14. Hamm LR, Sorrells SC, Harding JP, et al. Additional inves-tigations fail to alter the diagnosis of irritable bowel syndromein subjects fulfilling the Rome criteria. Am J Gastroenterol1999;94:1279–82.

15. Thompson WG, Heaton KW, Smyth GT, et al. Irritable bowelsyndrome in general practice: Prevalence, characteristics, andreferral. Gut 2000;46:78–82.

16. Drossman DA, McKee DC, Sandler RS, et al. Psychosocialfactors in the irritable bowel syndrome. A multivariate studyof patients and nonpatients with irritable bowel syndrome.Gastroenterology 1988;95:701–8.

17. Berg L. Data on file. The Research Unit in Primary Care,Tibro, Sweden.

18. Thompson WG, Heaton KW, Smyth GT, et al. Irritable bowelsyndrome: The view from general practice. Eur J Gastroen-terol Hepatol 1997;9:689–92.

19. Britt H, Miles DA, Bridges-Webb C, et al. A comparison ofcountry and metropolitan general practice. Aust Fam Physi-cian 1994;23:1116–21, 24–5.

20. Jones R. Self-care and primary care of dyspepsia: A review.Fam Pract 1987;4:68–77.

21. Loof L, Adami HO, Agenas I, et al. The Diagnosis andTherapy Survey October 1978–March 1983, health care con-sumption and current drug therapy in Sweden with respect tothe clinical diagnosis of gastritis. Scand J Gastroenterol 1985;20(suppl 109):35–9.

22. Kruis W, Thieme C, Weinzierl M, et al. A diagnostic score forthe irritable bowel syndrome. Its value in the exclusion oforganic disease. Gastroenterology 1984;87:1–7.

23. Doggan UB, U¨ nal S. Kruis scoring system and Manning’scriteria in diagnosis of irritable bowel syndrome: Is it better touse combined? Acta Gastroenterol Belg 1996;59:225–8.

24. Agreus L. The abdominal symptom study. An epidemiologicalsurvey of gastrointestinal and other abdominal symptoms inthe adult population of O¨ sthammar, Sweden. Thesis, UppsalaUniversity, Uppsala, Sweden 1993.

25. Ragnarsson G, Bodemar G. Pain is temporally related to eatingbut not to defecation in the irritable bowel syndrome (IBS).Patients’ description of diarrhea, constipation and symptomvariation during a prospective 6-week study. Eur J Gastroen-terol Hepatol 1998;10:415–21.

26. Agreus L, Svardsudd K, Nyre´n O, et al. Reproducibility andvalidity of a postal questionnaire. The abdominal symptomstudy. Scand J Prim Health Care 1993;11:252–62.

Reprint requests and correspondence:Lars Agreus, M.D.,Ph.D., Family Medicine Stockholm, Novum, SE-141 57 Stock-holm, Sweden.

Received June 14, 2000; accepted June 14, 2000.

Completing ColonoscopyWhenever a colonoscopic examination is indicated or de-termined to be necessary, a total examination of the entirecolon is required. The trained endoscopist should be able toreach the cecum in 95% of cases with no excuses for gender,prior surgery, body habitus, or pain tolerance. The authorsof the article in this issue, Andersonet al. (1) have foundthat, in women, the person’s size is inversely correlated withthe degree of difficulty in performing colonoscopy: thesmaller the body mass index, the more difficult is thecolonoscopy. The St. Marks’ group also attempted to ex-plain the difference in the degree of colonoscopic difficultyin women (as opposed to men) and found that, when mea-suring the length of the colon on barium enema examina-tion, the average female colon was longer than that of a malepatient despite the smaller abdominal cavity in women (2).The authors have also demonstrated that the presence ofdiverticular disease does not adversely impact on the com-pletion rate of colonoscopy, nor does a previous hysterec-tomy (1).

By personal observation, I have found that colonoscopicexaminations are much more difficult in younger patientsthan in older patients, in slender patients compared to obesepatients, and in women. Colonoscopy is also difficult in tall,fat men and in patients with severe diverticular disease. Ibelieve that the difficulty encountered with diverticular dis-ease is related to fixation, tortuosity, and acute angulationsof the colon. However, in the absence of massive divertic-ulosis, the mere presence of diverticulosis is not a limitingfactor for colonoscopy. The difficulty with colonoscopy inthe younger patient is that the mesocolon is relatively “tight”in younger patients and is intolerant to being stretched.Pulling or “stretch” on the mesocolon accounts for most ofthe discomfort during colonoscopy. As the instrument ispassed through the sigmoid colon, the loop that forms pullson the root of the mesentery and stretches the mesocolon. Inolder patients, the mesocolon is quite elastic, rendering itpossible to make a large loop in the sigmoid colon withoutthe perception of pain, whereas a smaller loop in youngerpersons can be quite painful.

An additional factor rendering the colonoscopic exami-nation somewhat more difficult in slender women is relatedto the relatively longer colon being folded into a smallerabdominal cavity. This alone accounts for a considerableamount of tortuosity throughout the colon, especially evi-dent in the sigmoid region. Another consideration that israrely mentioned is the acute angle of the mid-sigmoid/descending colon junction as the sigmoid colon ascendsfrom the pelvis over the uterus and then dips into the left

2681AJG – October, 2000 Editorials