Iome II: The Functional Gastrointestinal Disorders, 2nd Ed

Rome II presents the full reports from ten multinational working teams which not only detail the criteria for symptom based diagnosis of functional gastrointestinal disorders but also present the latest information on the pathophysiology, diagnostic approach and treatment of 24 functional GI disorders plus an additional new chapter on pediatric disorders.

This book can be used as both a textbook and an up to date reference source for anyone interested in clinical care or a comprehensive review of the field. It is must reading for clinicians and researchers. In bringing this new medical knowledge from the multinational working teams to primary care physicians and gastroenterologists throughout the world, this book advances a symptom based classification system developed as a new paradigm for the diagnosis and treatment of functional GI disorders so that patients suffering from these conditions may find the promise of relief contained in Rome II.

Rome II addresses some of the most puzzling and prevalent of chronic disorders. Functional gastrointestinal disorders, including irritable bowel syndrome, functional dyspepsia and chronic functional abdominal pain, are very commonly seen in specialty and general medical practices. Until recently, there have been no scientifically and psychologically based standards for approaching these patients. Nor have researchers found common frameworks within which to study the causes and treatments of functional gastrointestinal disorders.

Functional GI disorders historically have been considered second class. Clinicians and scientists paid little attention to these disorders, leaving patients dissatisfied with their care, and causing unnecessary diagnostic procedures. Funding agencies gave little attention to the investigation of these disorders. In the late 1980s, the multinational collaboration and publication of the work of the Rome Working Teams dramatically changed this field of medicine by legitimization of these disorders, resulting in an increase in research grants, pharmaceutical studies and publications.

Refining, expanding and updating that landmark work, the authors of Rome II report on validation studies of its original Diagnostic Criteria, new findings in basic and clinical research, the new classification these disorders in children, and promising new treatments on the horizon.

It has been said that only 10 percent of medical illnesses can be attributed to specific diseases; even patients with cancer vary greatly in their responses to it. According to the traditional biomedical concept of disease, the functional gastrointestinal disorders -- irritable bowel syndrome, functional dyspepsia, and others -- are ``nonentities,'' with no clear-cut structural, biochemical, or physiologic basis. Yet these disorders account for a considerable proportion of visits to gastroenterologists and primary care physicians. Elucidating the mechanisms of functional bowel disease and developing effective treatments are therefore major challenges.

Rome II: The Functional Gastrointestinal Disorders is the second edition of what has become the standard reference in the field of functional bowel diseases. Its purpose -- like that of the original edition, which was begun in Rome in 1988 and published in 1994 -- is to help clinicians and investigators make ``positive'' diagnoses of functional bowel disorders (rather than merely diagnoses of exclusion), understand the pathophysiology of these disorders, and make effective treatment decisions. This is a tall order for poorly understood diseases in which the pathophysiology is hopelessly complex and for which most published treatment trials are methodologically flawed.

As there are no disease-specific markers, the core of the book is a delineation of symptom-based diagnostic criteria for functional gastrointestinal disorders. These criteria are based on thorough reviews of the literature and consensus by seven multinational committees whose work culminated again in Rome, this time in 1998. These ``Rome criteria'' are analogous to the classifications of psychiatric disorders in the Diagnostic and Statistical Manual of Mental Disorders and are intended, in part, to reduce the need for costly and unnecessary tests to ``rule out organic disease'' in patients with functional disorders and to serve as a framework for research.

Rome II is already the new standard reference in the field. It is impressive in scope, organization, content, and clarity. No stone is left unturned in examining possible mechanisms of functional disease, and numerous treatment options -- ranging from home remedies and psychopharmacologic therapy to alternative and complementary approaches -- are critically reviewed.

Nearly one fourth of the book reviews ``neurogastroenterology,'' the study of enteric neural control of the gastrointestinal tract and its modulation by the central nervous system. Processes that are thought to underlie the functional bowel diseases, triggers and tests of sensorimotor dysfunction, drugs that modulate gut function, and recommendations for further research are considered in depth. Early-life experiences, stress, abuse, psychiatric disorders, and psychological tests are also explored. Each disorder is then categorized, defined, and discussed in detail with regard to diagnostic criteria, clinical evaluation, physiology, psychological features, and treatment. The concluding sections deal with the optimal design of treatment trials and questionnaires that can be used in research.

In reading this book, I had the sense that we are just scratching the surface. How does stress cause abdominal pain? What changes in the brain cause irregular bowel function or epigastric burning years after a traumatic event? Why do low-dose tricyclic antidepressants alleviate the symptoms of functional gastrointestinal disease? Answers to these and many other questions remain elusive. Nevertheless, the book serves the important purposes of organizing and cataloguing what we know about the functional disorders, providing clear working definitions, and describing the results and limitations of treatment trials. It also serves as a scaffolding on which new discoveries can be placed. Despite its length and detail, the writing is lucid, and the book is easy to read. The tables are well organized, the reference lists are comprehensive, and the index and an appended glossary are useful. Illustrations are straightforward and clear, though few in number and printed in uninspiring shades of gray. There are some potentially functional disorders that seem to be excluded -- excessive flatulence comes to mind (is it subsumed under bloating?) -- but these minor criticisms do not detract from the overall quality of this book, which is undoubtedly the bible of functional bowel diseases.

Lawrence S. Friedman, M.D.
Copyright © 2001 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.