Overview of functional bowel disorders

Overview of functional bowel disorders ISSN: 2394-0026 (P)Review Article ISSN: 2394-0034 (O)Overview of functional bowel disorders Tarjina Begum1, Anup K Das2* 1,2 Department of Medicine, Assam Medical College, Dibrugarh, Assam, IndiaAbstractThe true incidence of functional physical disorders is higher in general practice including functionalbowel disorders. It leads to a high socio-economic burden by way of delayed diagnosis. ROME IIIcriteria are used to diagnose these disorders. Although there are specific clinical diagnostic features,definite diagnostic investigations are unavailable. Recent scientific studies link the mind and body aspart of a system where their dysregulation can produce illness and disease where psycho-socialfactors do play a role in addition to genetic susceptibility and environmental factors. The brain-gutaxis is now an area of intense research in studying these functional disorders and psychotherapy,behavioral modification and psycho-pharmacotherapy are becoming increasingly important tomanage such disorders.Key wordsFunctional bowel disorders, Brain-Gut axis, Psycho-somatic disease, IBS, irritable bowel syndrome.Introduction the patients that translate into quite a high economic burden to the society by way ofOne of the most challenging tasks in clinical absenteeism, poor quality of life and medicalmedicine is the diagnosis and management of expenses. With rise in population, thesefunctional disorders which account for 36-50% disorders will definitely pose a diagnosticof all out patient consultations in hospital dilemma to us in future because there is alreadysetting [1]. This implies that the actual incidence a high prevalence of GI disorders in generalof functional physical disorders is higher in population [3].general practice [2]. The same is apparent inbowel diseases in gastroenterology, where Functional bowel disorderfunctional disorders cause significant distress to*Corresponding Author: Anup K Das A functional bowel disorder (FBD) is diagnosedE mail: [email protected] by characteristic symptoms for at least 12 weeks during the preceding 6 months in the absence ofReceived on: 06-09-2014 How to cite this article: Tarjina Begum, Anup K Das. Overview ofRevised on: 12-09-2014 functional bowel disorders. IAIM, 2014; 1(2): 34-43.Accepted on: 16-09-2014 Available online at www.iaimjournal.comInternational Archives of Integrated Medicine, Vol. 1, Issue. 2, October, 2014. Page 34Copy right © 2014, IAIM, All Rights Reserved.

Overview of functional bowel disorders ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)a structural or biochemical explanation [2]. It category i.e. functional bowel disorders out ofmust be understood that FBD is only a subgroup which irritable bowel syndrome (IBS) is by farof functional gastrointestinal disorders (FGID) the commonest. However, treatment of thesewhich have definite diagnostic criteria and these conditions is beyond the scope of this article.clinical criteria have been modified from time totime. Therefore, it is emphasized that there The symptoms of the FGID are derived frommust be chronological criteria to be fulfilled combinations of their physiologicalbefore making a diagnosis of FGID. These criteria determinants: a) increased motor reactivity, b)have been revised since the first consensus enhanced visceral hypersensitivity, c) alteredmeeting held in 1989 at Rome and are known as mucosal immune and inflammatory functionROME criteria, the latest being ROME III which is (which includes changes in bacterial flora), andfollowed in this presentation. It maintains the d) altered central nervous system (CNS)-entericprinciple of symptom-based diagnostic criteria nervous system (ENS) regulation (influenced bylike the DSM classification for mental disorders. psychosocial and socio cultural factors andThe classification relies on the organs where the exposures) [4, 5, 6]. For example, fecalsymptoms presumably are produced. They are in incontinence (category F1) may primarily be aorder from esophagus to anus. The recent disorder of motor function, while functionalclassification of FGID in adults and children is abdominal pain syndrome (category D) isshown in Table - 1. primarily understood as amplified central perception of normal visceral inputFor adults, the FGID include 6 major groups: (hypersensitivity to pain). IBS (category C1) isEsophageal (category A), Gastro duodenal more complex, and results from a combination(category B), Bowel (category C), Functional of dysmotility, visceral hypersensitivity, mucosalabdominal pain syndrome (category D), Biliary immune dysregulation, alterations of bacterial(category E), and Anorectal (category F). flora, and CNS-ENS dysregulation [7, 8]. The contribution of these factors may vary acrossEach category site contains several disorders, different individuals or within the sameeach having relatively specific clinical features. individual over time. Thus, the clinical value ofSo, the functional bowel disorders (category C) separating the functional gastro intestinal (GI)include: Irritable bowel syndrome (C1), symptoms into discrete conditions is that theyFunctional bloating (C2), Functional constipation can be reliably diagnosed and better treated.(C3) and Functional diarrhea (C4), whichanatomically are attributed to the small bowel, The Rome III classification system is based oncolon, and rectum. Thus, while symptoms (e.g., the premise that for each disorder there arediarrhea, constipation, bloating, pain) may symptom clusters that “breed true” acrossoverlap across these disorders, irritable bowel clinical and population groups [9]. Thissyndrome (C1) is more specifically defined as presumption provides a framework forpain associated with change in bowel habit, and identification of patients for research that isthis is distinct from functional diarrhea (C4), modified as new scientific data emerges. Thecharacterized by loose stools and no pain, or rationale for classifying the functional GIfunctional bloating (C2), where there is no disorders into symptom-based subgroups arechange in bowel habit. Each condition also has based on the site-specific differences betweendifferent diagnostic and treatment approaches. symptoms, i.e., the fact that symptoms resultIn this article, focus will be placed only to this from multiple influences, from epidemiologicInternational Archives of Integrated Medicine, Vol. 1, Issue. 2, October, 2014. Page 35Copy right © 2014, IAIM, All Rights Reserved.

Overview of functional bowel disorders ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)data showing similar frequencies of these modifiable by socio-cultural and psychosocialdisorders across cultures, and finally, out of the influences [12, 13].need for diagnostic standards in order toconduct clinical care and research. The application of this model of Engel to the Functional Gastrointestinal Disorders (FGID)The basic paradigm of the modern medicine has helps to explain how changes in early life,traditionally relied on the concepts promoted by genetic factors and environmental factors, mayDescartes of biological reductionism and affect the psychosocial developmentdualism, which in medicine, seeks to find a (susceptibility to life stress, psychological state,single biological etiology for every clinical coping skills, abnormal illness behavior, socialcondition [10]. In the last decades, we have support) and/or the development of gutmoved away from this reductionistic model of dysfunction (i.e., abnormal motility, visceraldisease to a more holistic paradigm of the hypersensitivity, inflammation, or alteredbiopsychosocial model of disease. Here, illness bacterial flora), all of which lead to the clinical(the person’s experience of ill health), and expression of the disorder. Furthermore, thesedisease (objective histopathological findings) are brain-gut variables mutually interact toviewed as equally important in understanding influence their expression. Therefore the FGIDthe clinical expression of a medical condition, are the clinical product of the interaction ofand this refuted the traditional reductionistic psychosocial factors and altered gut physiologymodel of disease. The reductionistic disease- via the brain-gut axis [14]. For example, anbased biomedical model harmonized with individual with a bacterial gastroenteritis orDescartes’ separation of mind and body at the other bowel disorder who has no concurrenttime when society was accepting the concept of psychosocial difficulties and good coping skillsseparation of church and state. What resulted may not develop the clinical syndrome or, if itwas permission to dissect the human body does develop, may not feel the need to seek(which was previously forbidden), so disease medical care. Another individual with coexistentwas defined by what was seen (i.e., pathology psychosocial co-morbidities, high life stress,based on abnormal morphology). This approach abuse history, or maladaptive coping, mayhas led to centuries of valuable research develop a FGID and visit more frequently theproducing appropriated treatments for many physician and have a worse clinical outcome.diseases. However, the concept of the mind (i.e., The number of studies and publications on thethe central nervous system, CNS) as being FGID has increased along with the progress ofamenable to scientific study or as playing a role newer investigative methods leading to widerin illness and disease was marginalized: The acceptance of these conditions by the physiciansmind was considered the seat of the soul, and than before. These studies have served towas not to be tampered with [11]. legitimize these conditions in a positive way, not just by exclusion of other disorders. TheMore recent scientific studies link the mind and assessment of motility has improved. The widerbody as part of a system where their use of the barostat, as the main technique fordysregulation can produce illness and disease. assessing visceral hypersensitivity has providedBy embracing this integrated understanding, the evidence for the role of visceral sensitivity inbiopsychosocial model allows for symptoms to understanding these conditions. Finally, anotherbe both physiologically multi determined and novel area of development has been the progress in brain imaging like positron emissionInternational Archives of Integrated Medicine, Vol. 1, Issue. 2, October, 2014. Page 36Copy right © 2014, IAIM, All Rights Reserved.

Overview of functional bowel disorders ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)tomography (PET), and functional magnetic important to know that only half of all patientsresonance imaging (fMRI) [8]. These modalities will consult their general physicians and of theseoffer a window into the central modulation of GI about 20% will need referral to a higher centre.function and its linkages to emotional and While approaching a suspected case of FBD, thecognitive areas which were not possible even a history is very important, as we have alreadydecade back [15]. Thus the nature of FGID as mentioned that the diagnostic criteria of FGIDdisorders of brain-gut interactions is now are symptom specific. They have no diseaseeminently amenable to scientific study. The markers [15]. We only investigate the symptomspsychological instruments permitting the of such patients. However, we must always lookcategorization and quantification of emotions, out for certain “ALARM SYMPTOMS” in all casesstress, and cognitions have also been better so that more dangerous, truly structural andstandardized, and these measures help us treatable (infectious/metabolic) conditions aredetermine the role of psychosocial factors on not missed. Therefore, FBD are diagnosed by asymptom generation, and its effect on quality of process of exclusion.life and health outcomes. These developmentsemphasize the role of brain-gut dysregulation in Irritable bowel syndromeFGID [14].Finally, the molecular investigation of brain and Irritable bowel syndrome (IBS) has a prevalencegut peptides, mucosal immunology, of 10-20% in western population and is the mostinflammation, and alterations in the bacterial common FGID [15]. Ethnic differences have beenflora of the gut provide the translational basis reported in a few studies. Cultural factors likefor GI symptom generation. All physicians now diet and socio-economic status may play a part.recognize the FGID as true clinical entities. These IBS is responsible for 40-60% of referrals indisorders are now a prominent part of gastroenterology outdoor patient departmentundergraduate and postgraduate medical most commonly involving age group of 30-50curricula, clinical training programs, and years [3]. It is a multi factorial disorder -international symposia. The number of papers in basically a dysregulation of gut-brain axis with GIthe FGID in peer-reviewed journals has motor and sensory dysfunction, enteric and CNSincreased dramatically. But now there are irregularities, neuro immune dysfunction and afuture challenges to be faced like a need for an post-infectious inflammation in some cases.improved understanding of the relationships Genetics and psycho-social factors may play abetween mind and gut, and the translation of role. Large numbers of IBS patients have a lowbasic neurotransmitter function into clinical visceral pain threshold. Disorder of gut motilitysymptoms and their impact on the patient’s is not universally present. True food allergy inhealth status and quality of life [15]. There is IBS is very uncommon. But many patients tellalso a need to educate clinicians and the general their doctors that particular food itemspublic on this rapidly growing knowledge and, in exacerbate their symptom(s). The exact etiologythe process, continue to legitimize these of IBS is unknown. The hall-mark symptoms aredisorders to society. a) lower abdominal pain/discomfort b) altered bowel function, and c) bloating. TheseThe approach to FBD (or any other FGID) aims symptoms are found in variable combinations inprimarily at excluding a structural/ anatomical/ different patients [16]. But, without pain, ahistopathological or biochemical anomaly. It is diagnosis of IBS is never made. The symptoms of abdominal pain, diarrhea or constipation orInternational Archives of Integrated Medicine, Vol. 1, Issue. 2, October, 2014. Page 37Copy right © 2014, IAIM, All Rights Reserved.

Overview of functional bowel disorders ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)both, mucus discharge in stool and changes in examination and occult blood, blood sugar,the form/appearance of stools may be complete blood count (CBC), C-reactive proteinprecipitated by a bout of gastroenteritis. The (CRP) and thyroid profile should be done in allabdominal pain is often relieved by defecation. cases.Non GI symptoms common in IBS are lethargy,poor sleep, fibromyalgia, backache, frequent Depending upon the predominant symptom, theurination and dyspareunia. differential diagnosis include Malabsorption (post gastrectomy, celiac sprue, pancreaticIt is usually a chronic recurrent, often life-long insufficiency), Lactose intolerance, Bacterialdisease, common in women (M: F = 2: 1) and no overgrowth, Alcoholism, IBD, HIV,diagnostic test is available for a definitive Endometriosis, Psychiatric disorders (panicdiagnosis. Similarly, physical examination is states/depression) and rarely GI endocrinenormal except for mild abdominal or rectal tumors.tenderness. Hence, we should try to take athorough history to identify the criteria that Because of the complex nature of IBS, treatmentdefine IBS first, and then try and establish the is never successful with any single modality andstool pattern - diarrhea is predominant (IBS-D) includes a combination of diet/ lifestyleor constipation (IBS-C), or both (IBS-A) [3]. This modifications, pharmacological, psychosocialis done by asking the patient about stool and complementary medicine strategies. Patientconsistency. This is important for treatment education and reassurance is important. It mustpurpose. Large volume stools, bloody stools, be stressed that survival in IBS is not lessgreasy stools and nocturnal diarrhea do not compared to normal people.occur in IBS. But mucus may be present in 50%cases. Recently, reports have indicated In patients of suspected IBS who do notoverlapping of other FGID like gastro esophageal respond, it is difficult to recommend how farreflux disease (GERD) and epigastric pain one has to proceed with further investigationssyndrome (functional dyspepsia) with IBS [16]. A [17]. This constitutes the smallest number of IBSdiagnosis of IBS is done in general practice cases (~5%). Patience is required from both theobserving the patient over time in most cases. sufferer and the healer and a realistic goalDietary and drug history, family history, social should be established after spending timehistory should be taken. discussing with each other. Often, a trial-and- error method of treatment is required. IntensityAfter this we must look out for the ALARM of symptoms and other co-morbid conditionsSYMPTOMS: Weight loss, Rectal bleed, Anemia, should be taken into account and treatment orFamily history of colorectal malignancy/ further investigation is individualizedInflammatory bowel disease, Fever, Nocturnal accordingly. However, a study has shown thatsymptoms, Persistent diarrhea, Severe approximately <10% of previously diagnosed IBSconstipation, High ESR/CRP and Age > 40 years. patients developed an organic gastro-intestinalThese symptoms hold true for all FGID so that disease. Similarly, in another study celiac diseasesimple initial evaluations of all cases are done to was diagnosed in 4% of cases who fulfilled thedetect serious diseases. Colonoscopy should be criteria for IBS previously but did not respond todone in all cases who are >50 years of age, treatment [18]. Therefore, in a minority ofpersistent diarrhea or severe constipation that patients, in spite of a multidisciplinary treatmentdo not respond to treatment. Stool routine approach if there is no response after 6 weeks,International Archives of Integrated Medicine, Vol. 1, Issue. 2, October, 2014. Page 38Copy right © 2014, IAIM, All Rights Reserved.

Overview of functional bowel disorders ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)and if any alarm symptoms appear or the IBS medications (opiods, calcium channel blockers,symptoms progress, or are atypical with a short antacids, anti-cholinergics, Iron, anticonvulsants,history, and age >45 years, then further antidepressants, diuretics or antispasmodics)evaluation may be ordered depending upon the and physical or mental retardation. Rarer causespredominant symptom [19]. These include: a) to exclude are anorexia nervosa, anorectalIBS-C: Colonic transit study, Anorectal motility/ disorders and small gut pseudo-obstruction. Asensory/ balloon expulsion test, Defecography, digital rectal examination should be alwaysPelvic MRI. b) IBS-D: Lactose/ bacterial performed. Alarm symptoms are: Bloody stools,overgrowth tests, Stool for giardia/ fat/ Weight loss, Evidence of Systemic illness andosmolality, Celiac antibodies (tTG IgA), Small Risk factors for Colo-rectal carcinomas. Chronicbowel/ large bowel biopsy. c) PP abdomen, constipation as a whole is a very commonsmall bowel follows through studies, CT/MR. condition with approximately 27% prevalence. However, only half of them will meet the ROMEIBS is a benign disease but the prognosis III criteria.depends upon length of history and ongoing lifestress (both indicating a lesser chance of Functional diarrhea (FD)improvement). At 7 years of follow up 55% willstill have symptoms, 21% will improve and only Functional diarrhea (FD) is also called non-13% will improve completely [17]. specific chronic diarrhea (NSCD) and is diagnosed by a daily passage of painless,Functional Constipation recurrent passage of 3 or more, large, unformed stools during a period of at least 4 weeks. It isFunctional Constipation diagnosed by at least 2 more common in young children and toddlers (6of the following [20]. – 36 months of age) but interestingly the children thrive well and this is the strongest a) Straining during 25% or more of pointer to the diagnosis [14]. There is no defecations. dehydration. FD is also seen in adults especially after a bout of acute gastro-enteritis. In many b) Lumpy/ hard stools during 25% or more adults, FD may occur due to small intestinal of defecations. bacterial over-growth. Alarm signs are failure to thrive (in spite of adequate caloric intake), c) Sense of incomplete evacuation or abdominal pain, blood in stool and emesis. Exact anorectal obstruction during 25% or cause is unknown but sorbitol, starch or fructose more of defecations. malabsorption may play a part by altering gut motility. It is usually self limiting and does not d) Manual evacuation of 25% or more of require treatment except for reassurance, but evacuations. the above mentioned food items may be avoided. However, celiac disease, infection and e) Less than 3 bowel movements per week. other inflammatory conditions need to be ruled Loose stools rarely occur in them out. Giardiasis can mimic FD but causes pain without laxative use. abdomen, not present in FD. In any case, infectious diarrhea is to be ruled out.It is always necessary to exclude IBS as well asother causes like colonic or rectal malignancies/inflammatory conditions, neurological diseases(parkinsonism, spinal injuries, multiple sclerosis,scleroderma), metabolic and endocrinal diseases(hypokalemia, hypercalcemia, hypocalcemia,uremia, hypothyroidism, diabetes mellitus),International Archives of Integrated Medicine, Vol. 1, Issue. 2, October, 2014. Page 39Copy right © 2014, IAIM, All Rights Reserved.

Overview of functional bowel disorders ISSN: 2394-0026 (P)Functional Bloating ISSN: 2394-0034 (O) AcknowledgementFunctional Bloating is the persistent feeling of Authors acknowledge the immense helpabdominal fullness with discomfort and is quite received from the scholars whose articles arecommon especially in elderly females. [15] cited and included in references of thisTreatable conditions that need to be excluded manuscript. The authors are also grateful toare Lactose intolerance, carbonated drinks authors / editors /publishers of all those articles,(fructose intolerance), bulking agents, bacterial journals and books from where the literature forovergrowth and constipation. In functional this article has been reviewed and discussed.bloating there is no altered bowel or stoolformation. Obstructive causes need to be ruled Referencesout by history and physical examination. Rarelyimaging studies are needed. 1. Jones J, Boorman J, Cann P, et al. British Society of Gastroenterology guidelinesApart from these FBD there are several for the management of irritable bowelconditions which do not or partially fulfill the syndrome. Gut, 2000; (Suppl II) 47: ii1 –criteria laid down by ROME III meet, and they ii19.are yet to be specified properly [9]. Asmentioned earlier, FGID may overlap in the 2. Drossman DA. Diagnostic criteria forsame patient. Treatment of these disorders is functional gastrointestinal disorders. In:dependent upon the presenting/predominant Drossman DA, Corazziari E, Talley NJ etsymptoms and is highly individualized. al. eds Rome II. The functional gastrointestinal disorders. 2nd edition,Conclusion Lawrence, KS. Allen Press, 2000, p. 659- 668.In conclusion, FGID and especially FBD like IBSare very common. The etiology is unknown. The 3. Saito YA, Schoenfeld P., Locke GRI. Theincidence is high in general practice. They cause epidemiology of irritable bowelsignificant distress to the patients and lead to syndrome in North America: Apoor quality of life in the majority. It is systematic review. Am J Gastroenterol,recommended that well-set criteria are followed 2002; 97: 1910-1915.while diagnosing these conditions. Thisprocedure, along with awareness of alarm 4. Azpiroz F, Eck P, Whitehead WE.symptom/signs will guide the physicians toward Anorectal functional testing: Review ofan optimal and cost-effective management of collective experience. Am Jthese patients which at present is not very Gastroenterol, 2002; 97: 232-240.satisfactory. Multiple therapeutic strategiesincluding lifestyle changes and psychiatric help is 5. Parkman HP, Hasler WL, Fisher RS. AGAoften needed to manage these patients. Better technical review on the diagnosis andways to identify which patients will respond to treatment of gastroparesis.specific treatments are required to be Gastroenterology, 2004; 128: 209-224.investigated in future. 6. Pandolfino JE, Kahrilas PJ. AGA technical review of the clinical use of esophageal manometry. Gastroenterology, 2004; 128: 209-224. 7. Whitehead WE, Delvaux M. Standardization procedures for testingInternational Archives of Integrated Medicine, Vol. 1, Issue. 2, October, 2014. Page 40Copy right © 2014, IAIM, All Rights Reserved.

Overview of functional bowel disorders ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)smooth muscle tone and sensory 16. Yarandi SS, Nasseri-Moghaddam S, Mostajabi P, et al. Overlappingthresholds in the gastrointestinal tract. gastroesophageal reflux disease and irritable bowel syndrome: IncreasedDig Dis Sci, 1994; 42: 223-241. dysfunctional symptoms. World J Gastroenterol, 2010; 16(10): 232-1238.8. Drossman DA. Brain imaging and its 17. Owens DM, Nelson DK, Talley NJ. The irritable bowel syndrome: Long-termimplications for studying centrally prognosis and the physician-patient interaction. Ann Intern Med, 1995; 122:targeted treatments in IBS: A primer for 107-112. 18. Ford AC, Chey WD, Talley NJ, et al. Yieldgastroenterologists. Gut, 2005; 54: 569- of diagnostic tests for celiac disease in individuals with symptoms suggestive of573. irritable bowel syndrome: Systematic review and meta-analysis. Arch Intern9. Drossman DA. The functional Med, 2009; 169-651. 19. Spiller R, Aziz Q, Creed F, et al.gastrointestinal disorders and the Rome Guidelines on the irritable bowel syndrome: Mechanisms and practicalIII process. Gastroenterology, 2006; 130: management. Gut, 2007; 56: 1770-1798. 20. Garrigues V, Galvez C, Ortiz V, et al.1377-1390. Prevalence of constipation: Agreement among several criteria and evaluation of10. Drossman DA. Presidential address: the diagnostic accuracy of qualifying symptoms and self reported definitionsGastrointestinal illness and the in a population-based survey in Spain. Am J epidemiol, 2004; 159: 520-6.biopsychosocial model. Psychosom Med, Source of support: Nil1998; 60: 258-267. Conflict of interest: None declared.11. Descartes R. Discours de la method.,Vrin, Paris, 1992.12. Engel GL. The need for a new medicalmodel: A challenge for biomedicine.Science, 1977; 196: 129-13.13. Engel GL. The clinical application of thebiopsychosocial model. Am J Psychiatry,1980; 147: 535-544.14. Jones MP, Dilley JB, Drossman DA,Crowel MD. Brain-gut connections infunctional GI disorders: Anatomic andphysiologic relationships.Neurogastroent Motil, 2006; 18: 91-103.15. H. Vahedi, R Ansari, MM MirNasseri, etal. Irritable Bowel Syndrome: A reviewarticle. Middle East Journal of DigestiveDiseases, 2010; 2(2): 66-77.International Archives of Integrated Medicine, Vol. 1, Issue. 2, October, 2014. Page 41Copy right © 2014, IAIM, All Rights Reserved.

Overview of functional bowel disorders ISSN: 2394-0026 (P)Table – 1: Classification of Functional Bowel Diseases. ISSN: 2394-0034 (O)FUNCTIONAL GASTROINTESTINAL DISORDERS Page 42 A. Functional Esophageal DisordersA1 Functional heartburnA2 Functional chest pain of presumed esophageal originA3 Functional dysphagiaA4 Globus B. Functional Gastro-duodenal disordersB1 Functional dyspepsia B1a Postprandial distress syndrome(PDS) B1b Epigastric pain syndrome (EPS)B2 Belching disorders B2a Aerophagia B2b Unspecified excessive belchingB3 Nausea and vomiting disorders B3a Chronic idiopathic nausea (CIN) B3b Functional vomiting B3c Cyclic vomiting syndrome (CVS)B4 Rumination syndrome in adults C. Functional Bowel DisordersC1 Irritable bowel syndromeC2 Functional bloatingC3 Functional constipationC4 Functional diarrheaC5 Unspecified functional bowel disorders D. Functional Abdominal Pain Syndrome E. Functional Gallbladder and Sphincter of Oddi DysfunctionE1 Functional gallbladder disorderE2 Functional biliary SO disorderE3 Functional pancreatic SO disorder F. Functional Anorectal DisordersF1 Functional fecal incompetenceF2 Functional anorectal pain F2a : Chronic proctalgia F2a1 : levator ani syndrome F2a2 : Unspecified functional anorectal pain F2b : Proctalgia fugaxF3 Functional defecation disorders F3a: Dyssenergic defecation F3b: Inadequate defecatory propulsion G. Functional Disorders : Infants and ToddlersG1 Infant regurgitationInternational Archives of Integrated Medicine, Vol. 1, Issue. 2, October, 2014.Copy right © 2014, IAIM, All Rights Reserved.

Overview of functional bowel disorders ISSN: 2394-0026 (P)G2 Infant rumination syndrome ISSN: 2394-0034 (O)G3 Cyclic vomiting syndromeG4 Infant colicG5 Functional diarrheaG6 Infant dyscheziaG7 Functional constipationH. Functional Disorders : Children and AdolescentsH1 Vomiting and aerophagiaH1a : Adolescent rumination syndromeH1b : Cyclic vomiting syndromeH1c : AerophagiaH2 Abdominal pain related FGIDH2a: Functional dyspepsiaH2b: Irritable Bowel SyndromeH2c: Abdominal migraineH2d : Childhood functional abdominal pain H2d1: Childhood functional abdominal pain syndromeH3 Constipation and incontinenceH3a: Functional constipationH3b: Non-retentive fecal incontinenceInternational Archives of Integrated Medicine, Vol. 1, Issue. 2, October, 2014. Page 43Copy right © 2014, IAIM, All Rights Reserved.