Diagnoses and symptoms associated with a DGBI as found in:
Gut Feelings: Disorders of Gut Brain Interactions and the Patient-Provider Relationship
The Disorders of Gut-Brain Interaction (DGBI)
We provide in the table below all the adult DGBIs, categorized by their main domains: esophageal, gastroduodenal, bowel, centrally mediated, gallbladder and biliary, and anorectal. Then we list the pediatric DGBIs, categorized by neonate/toddler (0-4) and child/adolescent (4 and older) domains. Included are links to explanatory videos to aid in the understanding of these conditions and their treatments.
Diagnostic studies and treatments, including dosages of drugs, are recommended from the medical literature and my clinical experience. For the most part, these recommendations conform to the practices of gastroenterologists working in the field of DGBI. Some of the treatments are considered “off label,” meaning that they are not necessarily approved by the FDA for the condition discussed but have shown benefit in the scientific literature. Further, the recommendations I have made are done so in general for these disorders and may not specifically apply to your clinical situation. The recommendations are a guide for you to learn about these treatments and to discuss them with your doctor.
Second, unless otherwise indicated, diagnosing a DGBI by Rome IV criteria requires that the symptoms described must have begun at least 6 months before the diagnosis is made and then must meet full Rome diagnostic criteria for at least 3 months. We require this to eliminate short-lived symptoms (e.g., acute gastroenteritis or discomforts from overeating) that may occur from time to time. Those are common symptoms that would not warrant a DGBI diagnosis.
A. Esophageal Disorders
| Functional Disorder | Functional definition and some links to more information |
|---|---|
| A1. Functional Chest Pain | Recurring, unexplained chest pain behind the sternum that is not experienced as heartburn but is believed to be related to the esophagus. Heart disease should be excluded by medical evaluation or cardiac diagnostic studies. |
| A2. Functional Heartburn | Burning discomfort or pain that is experienced behind the breastbone (retrosternal) that does not respond to acid-blocking treatments and is not caused by any structural diagnosis or motility disorder. |
| A3. Reflux Hypersensitivity | Heartburn or chest pain when endoscopy and pH studies are normal, but symptoms occur when acid enters the esophagus. Esophageal PH testing shows no increased acid, but the esophagus is found to be sensitive to acid. https://romedross.video/2FtbM1H |
| A4. Globus | Persistent or intermittent non-painful sensation of having a lump or foreign body in the throat. It occurs episodically and is located in the midline above the sternal notch. ESOPHAGEAL |
| A5. Functional Dysphagia | Sense of solid or liquid foods sticking, lodging, or passing abnormally through the esophagus. https://romedross.video/2M8N5ez |
B. Gastroduodenal Disorders
| Functional Disorder | Functional definition and some links to more information |
|---|---|
| B1. Functional Dyspepsia | Any of the following apply: 1) The unpleasant sensation of food staying in the stomach after a meal ("postprandial fullness"); 2) the unpleasant feeling that the stomach is overfilled soon after starting to eat ("early satiety"); 3) subjective, intense pain in the area just above the stomach ("epigastric pain") and/or 4) unpleasant, subjective sensation of heat in the epigastrium. These symptoms significantly impact usual activities. There are two subtypes of functional dyspepsia, as shown below in B1a and B1b. They may overlap. https://romedross.video/36uTGaA |
| -B1a. Postprandial Distress Syndrome (PDS) | Uncomfortable sensation of being too full soon after eating a meal or becoming full so early that eating a regular-sized meal is prevented. PDS is characterized exclusively by meal-induced symptoms. |
| -B1b. Epigastric Pain Syndrome (EPS) | Epigastric pain or burning that does not occur exclusively after meals, may occur during fasting, and may be improved by food. |
| B2. Belching Disorders | The audible escape of air from the esophagus or the stomach into the pharynx. This is only considered a disorder when it is excessive and becomes troublesome. Belching disorders are sub-classified into gastric belching or supragastric belching, described below in B2a and B2b. |
| -B2a. Excessive Supragastric Belching (from esophagus) | Excessive belching that occurs more than 3 days a week, caused by gas that originates from the stomach. See B2, above, for a fuller description. |
| -B2b. Excessive Gastric Belching (from stomach) | Excessive belching that occurs more than 3 days a week, caused by gas that originates from the stomach. See B2, above, for a fuller description. |
| B3. Nausea and Vomiting Disorder | Nausea is the unpleasant sensation of needing to vomit, typically felt in the upper abdomen immediately above the stomach, or in the throat (see B3a below). Vomiting is the forceful oral expulsion of gastrointestinal contents associated with contraction of the abdominal and chest wall muscles (see B3b below). http://bit.ly/2wW5hiD |
| -B3a. Chronic Nausea Vomiting Syndrome (CNVS) | Nausea occurring at least one day a week that is severe enough to impact usual activities, and one or more vomiting episodes a week. Eating disorders and self-induced vomiting must be excluded, and tests (including an upper endoscopy) find no evidence of organic abnormality. http://bit.ly/2wW5hiD |
| -B3b. Cyclic Vomiting Syndrome (CVS) | Intermittent stereotypical episodes of intense vomiting (up to 30 times a day) that may occur multiple times a year, lasting for a week or more, and the absence of nausea and vomiting between episodes http://bit.ly/2wW5hiD |
| -B3c. Cannabinoid Hyperemesis Syndrome (CHS) | Episodes of vomiting similar to CVS in their onset, duration, and frequency, but they occur after prolonged, excessive cannabis use and stop when cannabis use is discontinued. https://romedross.video/2FtbM1H |
| B4. Rumination Syndrome | Repetitive, effortless regurgitation of recently eaten food into the mouth, which is then re-swallowed or spit out. Regurgitation is not preceded by retching and occurs before the food has turned into acid. https://theromefoundation.org/q-a-rumination-2/ |
C. Bowel Disorders
| Functional Disorder | Functional definition and some links to more information |
|---|---|
| C1. Irritable Bowel Syndrome (IBS) | A bowel disorder in which recurrent abdominal pain is related to defecation and associated with constipation, diarrhea, or a mixture of both; abdominal bloating and distension may also be present. The IBS subtypes C, D, M, and U are differentiated by relative proportions of the stool form, as discussed below. https://romedross.video/Q_A_IBSCD |
| -IBS with Predominant Constipation (IBS-C) | IBS with more than one-fourth (25%) of bowel movements that are hard or lumpy (Types 1 and 2 on Bristol Stool Form Scale – BSFS). https://romedross.video/2NrTXVe |
| -IBS with Predominant Diarrhea (IBS-D) | IBS with more than one-fourth (25%) of bowel movements that are loose or watery (Types 6 and 7 on BSFS) https://romedross.video/2GJIEnt |
| -IBS with Mixed Bowel Habits (IBS-M) | IBS with a mixture of hard/lumpy and loose/watery bowel movements |
| -IBS Unclassified (IBS-U) | IBS in which bowel habits cannot be accurately categorized into 1 of the 3 classifications listed above. |
| C2. Functional Constipation | Defecation is usually difficult, infrequent, or incomplete. Abdominal pain or bloating may be present but do not predominate (as they do with IBS-C). Patients meeting criteria for IBS-C should be excluded http://bit.ly/2HCBiV1 https://romedross.video/11_15_19IBSCD |
| C3. Functional Diarrhea | Loose or watery stools, without predominant abdominal pain or bothersome bloating, occurring 25% of the time or more. Patients meeting criteria for IBS-D should be excluded. https://romedross.video/2GJIEnt |
| C4. Functional Abdominal Bloating/Distension | Recurrent bloating and distension of the abdomen that occurs on average at least 1 day a week and predominates over other symptoms. Patients with other bowel disorders, as listed above, should be excludedhttp://bit.ly/2NHQH5i. |
| C5. Unspecified Functional Bowel Disorder | Bowel symptoms, including abdominal pain or change in bowel habits that do not have an organic cause and do not meet criteria for IBS or functional constipation, diarrhea, or abdominal bloating/distention disorders. |
| C6. Opioid-Induced Constipation | New or worsening symptoms of constipation when initiating, changing, or increasing opioid therapy. http://bit.ly/2Pm9wLV |
D. Centrally Mediated Disorders of Gastrointestinal Pain
| Functional Disorder | Functional Definition and link to more information |
|---|---|
| D1. Centrally Mediated Abdominal Pain Syndrome (CAPS) | Continuous, nearly continuous, or frequently recurrent abdominal pain that is often severe and not or rarely related to changes in gut function such as eating or defecation. The pain is not feigned nor related to another gastrointestinal disorder. The chronic and severe pain associated is a hallmark complaint. https://romedross.video/2ZbDTcW |
| D2. Narcotic Bowel Syndrome (NBS) / Opioid-Induced GI Hyperalgesia | Development of (or increases in) abdominal pain associated with continuous or increasing dosages of opioids. The pain is not explained by other medical diagnoses. When opioid use ends, improvement or resolution will occur. http://bit.ly/2Pm9wLV |
E. Gallbladder and Sphincter of Oddi (SO) Disorders
| Functional Disorder | Functional definition and link to more information |
|---|---|
| E1. Biliary Pain | Pain that is episodic and located in the epigastrium (upper central region of the abdomen) and/or right upper quadrant that lasts 30 minutes or longer and is severe enough to interrupt daily activities or lead to an emergency room visit. https://romedross.video/2KcceGh |
| -E1a. Functional Gallbladder Disorder | Biliary pain (see E1) in the absence of gallstones or other structural pathology. https://romedross.video/2KcceGh |
| -E1b. Functional Biliary Sphincter of Oddi (SO) Disorder | Biliary pain (see E1) in the absence of bile duct stones or other structural abnormalities that is associated with abnormal liver enzymes or a dilated bile duct (but not both). Often, the gallbladder has been surgically removed https://romedross.video/2KcceGh |
| E2. Functional Pancreatic SO Disorder | Biliary pain (See E1) associated with episodes of pancreatitis (inflammation of the pancreas associated with elevated pancreatic enzymes). Patients with unexplained attacks of pancreatitis are often found to have elevated pancreatic sphincter pressure. |
F. Anorectal Disorders
| Functional Disorder | Functional definition and link to more information |
|---|---|
| F1. Fecal Incontinence | Recurrent uncontrolled passage of fecal material for at least 3 months |
| F2. Functional Anorectal Pain | Three types of functional anorectal pain disorders have been described and are explained below (see F2a, F2b, F2c). They are primarily distinguished by the duration of pain and the presence or absence of anorectal tenderness but overlap significantly.https://romedross.video/QA1_24_20PFD https://romedross.video/Q_A_RectalPainExam |
| -F2a. Levator Ani Syndrome | Pain that is often described as a vague, dull ache, or a sensation of pressure high in the rectum lasting 30 minutes or longer. It is often worse when sitting than when standing or lying down. Physical examination reveals tenderness when the doctor presses on the pelvic floor (posterior traction of the levator) muscle. Other structural disorders of the pelvic floor must be excluded. https://romedross.video/34cjdXS |
| -F2b. Unspecified Functional Anorectal Pain | Same symptoms as Levator Ani Syndrome, but upon rectal exam, there is no tenderness when the doctor presses on the levator muscle. |
| -F2c. Proctalgia Fugax | Recurrent episodes of pain in the rectal area, lasting for a few seconds to several minutes (up to 30 minutes) and then disappearing completely. It has been described as cramping, gnawing, aching, or stabbing; and may range from uncomfortable to unbearable. An attack may interrupt normal activities, and symptoms may awaken the patient from sleep. |
| F3. Functional Defecation Disorders (FDD) | Also called pelvic floor dyssynergia. Frequent excessive straining, feeling of incomplete evacuation with defecation, and at times digital facilitation of bowel movements. The pelvic floor muscles contract with defecation, rather than relaxing, as they should, or there is not enough pressure (propulsive force) to defecate. (See F3a and F3b below.) http://bit.ly/2C3VCMO |
| -F3a. Inadequate Defecatory Propulsion | Inadequate propulsive force to defecate properly http://bit.ly/2HCBiV1 |
| -F3b. Dyssynergic Defecation | Inappropriate or paradoxical contraction of the pelvic floor with failure to relax the levator muscle (puborectalis), associated with straining and difficulty with evacuating. http://bit.ly/2HCBiV1 |
G. Childhood Functional GI Disorders: Neonate/Toddler (Age 0-4)
| Functional Disorder | Functional definition and link to more information |
|---|---|
| G1. Infant Regurgitation | The involuntary return of swallowed food or secretions into or out of the esophagus, mouth, or nose. It differs from vomiting, which involves a reflex in which gastric contents are forcefully expelled. |
| G2. Rumination Syndrome | Habitual regurgitation of stomach contents into the mouth for self-stimulation caused by repetitive contractions of the abdominal muscles. |
| G3. Cyclic Vomiting Syndrome (CVS) | Stereotypical and repeated episodes of vomiting without retching that last from hours to days, with intervening periods of return to baseline normal health. Typically, vomiting episodes are separated by weeks or months. |
| G4. Infant Colic | Behavioral syndrome of early infancy (less than 5 months of age) involving recurrent or prolonged periods of crying, fussing, irritability, and hard-to-soothe behavior. More likely to occur in the afternoon or evening. |
| G5. Functional Diarrhea | Daily and recurrent painless passage of 4 or more large, un-formed stools for 4 or more weeks, beginning in infancy or pre-school years. No evidence of failure to thrive. |
| G6. Infant Dyschezia | Straining for at least 10 minutes, with crying, before the successful or unsuccessful passage of soft stools. The child may turn red or purple in the face with each effort to defecate. Symptoms usually persist for 10-20 minutes. Stools pass several times a day. |
| G7. Functional Constipation | Infrequent (2 or fewer per week) or painful defecation in infants and toddlers associated with excessive stool retention and hard or large-diameter stools; in older children, it may be related to fecal incontinence and withholding behavior. |
H. Childhood Functional GI Disorders: Child/Adolescent (Age 5 or older)
| Functional Disorder | Functional definition and link to more information |
|---|---|
| H1. Functional Nausea and Vomiting Disorders | Nausea is an unpleasant feeling, usually in the epigastrium or throat, associated with a sense of needing to vomit. Vomiting is the forceful expulsion of upper gastrointestinal contents following the contraction of gut and the thoracic and abdominal muscles. It is different from regurgitation or rumination, in which the movement of gastric contents into the mouth is effortless. See H1a and H1b, below, for definitions of the sub-classifications http://bit.ly/2wW5hiD |
| -H1a. Cyclic Vomiting Syndrome (CVS) | Stereotypical and repeated episodes of intense vomiting, separated by weeks or months, and with a return to baseline health between episodes. |
| -H1b. Functional Nausea and Functional Vomiting | These disorders are sub-classified and described below (see H1b1 and H1b2). |
| -H1b1. Functional Nausea | Bothersome nausea is the predominant symptom, occurring at least twice a week, and generally not related to meals. |
| -H1b2. Functional Vomiting | On average, one or more episodes of vomiting per week that are not self-induced or related to an eating disorder or rumination. |
| -H1c. Rumination Syndrome | Repeated regurgitation into the mouth of recently eaten food, with subsequent re-swallowing or expulsion. The symptom begins soon after ingestion of a meal, is not associated with retching and does not occur during sleep. |
| -H1d. Aerophagia | Excessive swallowing of air that causes abdominal distension, which becomes progressively worse during the day. Air swallowing may be visible, is often audible, and results in excessive belching or flatus. |
| H2. Functional Abdominal Pain Disorders | Disorders in which pain is the main symptom. These are sub-classified and defined below (see H2a, H2a1, H2a2, H2b, H2c, and H2d). |
| -H2a. Functional Dyspepsia | Upper gastrointestinal discomfort that may include a combination of unpleasant features, including a sensation of fullness after eating, early satiety, and upper abdominal pain or burning. The symptoms can cause significant impairment in quality of life. |
| -H2a1. Postprandial Distress Syndrome | Bothersome fullness soon after a meal or early satiety that prevents finishing a regular-sized meal. May include upper abdominal bloating, nausea, or excessive belching. |
| -H2a2. Epigastric Pain Syndrome | Bothersome pain or burning localized to the epigastrium (severe enough to interfere with normal activities). Pain is not generalized or localized to other abdominal or chest regions and is not relieved by defecation or passage of flatus. |
| -H2b. Irritable Bowel Syndrome (IBS) | Abdominal discomfort or pain associated with defecation or disordered defecation, and a change in the frequency and form (appearance) of the stool. |
| -H2c. Abdominal Migraine | Short but intense and paroxysmal episodes of abdominal pain lasting one hour or more, commonly separated by weeks to months, and associated with incapacitating symptoms that interfere with activities. Symptoms are often associated with loss of appetite, nausea and vomiting, headache, sensitivity to light, and pale skin. |
| -H2d. Functional Abdominal Pain—NOS | Episodic or continuous abdominal pain not related to eating or defecation at least 4 times a month that do not meet the criteria for IBS, functional dyspepsia, or abdominal migraine. |
| H3. Functional Defecation Disorders | These disorders relate to symptoms associated with the passage of stool. They are sub-classified and described below (see H3a and H3b). |
| -H3a. Functional Constipation | Infrequent bowel movements (2 or fewer per week), associated with painful passage of hard stools, the passage of a large-diameter stool or fecal incontinence. Involuntary leakage of feces may occur several times a day if a rectal impaction is present. |
| -H3b. Nonretentive Fecal Incontinence | Repeated passage of stool in a place inappropriate for the social context that is not associated with fecal retention. |