Original Contribution

Functional GI Disorders

The Prevalence and Impact of Overlapping Rome IV-Diagnosed Functional Gastrointestinal Disorders on Somatization, Quality of Life, and Healthcare Utilization: A Cross-Sectional General Population Study in Three Countries

  • The American Journal of Gastroenterology volume 113, pages 8696 (2018)
  • doi:10.1038/ajg.2017.421
  • Download Citation



The population prevalence of Rome IV-diagnosed functional gastrointestinal disorders (FGIDs) and their cumulative effect on health impairment is unknown.


An internet-based cross-sectional health survey was completed by 5,931 of 6,300 general population adults from three English-speaking countries (2100 each from USA, Canada, and UK). Quota-based sampling was used to generate demographically balanced and population representative samples with regards to age, sex, and education level. The survey enquired for demographics, medication, surgical history, somatization, quality of life (QOL), doctor-diagnosed organic GI disease, and criteria for the Rome IV FGIDs. Comparisons were made between those with Rome IV-diagnosed FGIDs against non-GI (healthy) and organic GI disease controls.


The number of subjects having symptoms compatible with a FGID was 2,083 (35%) compared with 3,421 (57.7%) non-GI and 427 (7.2%) organic GI disease controls. The most frequently met diagnostic criteria for FGIDs was bowel disorders (n=1,665, 28.1%), followed by gastroduodenal (n=627, 10.6%), anorectal (n=440, 7.4%), esophageal (n=414, 7%), and gallbladder disorders (n=10, 0.2%). On average, the 2,083 individuals who met FGID criteria qualified for 1.5 FGID diagnoses, and 742 of them (36%) qualified for FGID diagnoses in more than one anatomic region. The presence of FGIDs in multiple regions was associated with increasing somatization, worse mental/physical QOL, more medical therapies, and a higher prevalence of abdominal surgeries; all P<0.001. Notably, individuals with FGIDs in multiple regions had greater somatization and worse QOL than organic GI disease controls.


Roughly a third of the general adult population fulfils diagnostic criteria for a Rome IV FGID. In a third of this subset multiple GI regions are involved and this overlap is associated with increased health impairment.

  • Subscribe to The American Journal of Gastroenterology for full access:



Additional access options:

Already a subscriber?  Log in  now or  Register  for online access.


  1. 1.

    , . Rome IV-functional GI disorders: disorders of gut-brain interaction. Gastroenterology 2016;150:1257–1261.

  2. 2.

    . functional gastrointestinal disorders: history, pathophysiology, clinical features and Rome IV. Gastroenterology 2016;150:1262–1279.

  3. 3.

    . Review article: epidemiology and quality of life in functional gastrointestinal disorders. Aliment Pharmacol Ther 2004;20:31–39.

  4. 4.

    . Functional gastrointestinal disorders as a public health problem. Neurogastroenterol Motil 2008;20:121–129.

  5. 5.

    , , et al. U.S. householder survey of functional gastrointestinal disorders. Prevalence, sociodemography, and health impact. Dig Dis Sci 1993;38:1569–1580.

  6. 6.

    . The epidemiology of functional gastrointestinal disorders in North America. Gastroenterol Clin North Am 1996;25:1–19.

  7. 7.

    , , . Epidemiology and health care seeking in the functional GI disorders: a population-based study. Am J Gastroenterol 2002;97:2290–2299.

  8. 8.

    , , et al. Overlap of gastrointestinal symptom complexes in a US community. Neurogastroenterol Motil 2005;17:29–34.

  9. 9.

    , , et al. Epidemiology of the functional gastrointestinal disorders diagnosed according to Rome II criteria: an Australian population-based study. Intern Med J 2006;36:28–36.

  10. 10.

    , , et al. Systematic review and meta-analysis of the prevalence of irritable bowel syndrome in individuals with dyspepsia. Clin Gastroenterol Hepatol 2010;8:401–409.

  11. 11.

    , . Prevalence of, and risk factors for, chronic idiopathic constipation in the community: systematic review and meta-analysis. Am J Gastroenterol 2011;106:1582–1591 quiz 1581, 1592.

  12. 12.

    , . Global prevalence of and risk factors for irritable bowel syndrome: a meta-analysis. Clin Gastroenterol Hepatol 2012;10:712–721.e714.

  13. 13.

    , . Prevalence of gastro-esophageal reflux-type symptoms in individuals with irritable bowel syndrome in the community: a meta-analysis. Am J Gastroenterol 2012;107:1793–1801 quiz 1802.

  14. 14.

    , , et al. Global prevalence of, and risk factors for, uninvestigated dyspepsia: a meta-analysis. Gut 2015;64:1049–1057.

  15. 15.

    , , et al. Functional gastrointestinal disorders diagnosed by Rome III questionnaire in Korea. J Neurogastroenterol Motil 2011;17:279–286.

  16. 16.

    , , et al. The prevalence of functional gastrointestinal disorders in the chinese air force population. Gastroenterol Res Pract 2013;2013:497585.

  17. 17.

    , , et al. Irritable bowel syndrome in middle-aged and elderly Palestinians: its prevalence and effect of location of residence. Am J Gastroenterol 2014;109:723–739.

  18. 18.

    , , et al. Somatic comorbidities of irritable bowel syndrome: a systematic analysis. J Psychosom Res 2008;64:573–582.

  19. 19.

    , . Irritable bowel syndrome and somatization. Neurogastroenterol Motil 2015;27:740.

  20. 20.

    , , et al. Irritable bowel syndrome is significantly associated with somatisation in 840 patients, which may drive bloating. Aliment Pharmacol Ther 2015;41:449–458.

  21. 21.

    , , et al. The presentation of irritable bowel syndrome in the context of somatization disorder. Clin Gastroenterol Hepatol 2004;2:787–795.

  22. 22.

    , , . The impact of functional gastrointestinal disorders on quality of life. Am J Gastroenterol 2000;95:67–71.

  23. 23.

    , , et al. Initial poor quality of life and new onset of dyspepsia: results from a longitudinal 10-year follow-up study. Gut 2007;56:321–327.

  24. 24.

    , , et al. Biliary events and an increased risk of new onset irritable bowel syndrome: a population-based cohort study. Aliment Pharmacol Ther 2008;28:334–343.

  25. 25.

    , , . Irritable bowel syndrome in women having diagnostic laparoscopy or hysterectomy. Relation to gynecologic features and outcome. Dig Dis Sci 1990;35:1285–1290.

  26. 26.

    , . Irritable bowel syndrome and surgery: a multivariable analysis. Gastroenterology 2004;126:1665–1673.

  27. 27.

    , , et al. Factors that predict relief from upper abdominal pain after cholecystectomy. Clin Gastroenterol Hepatol 2011;9:891–896.

  28. 28.

    , . Epidemiology of cholecystectomy and irritable bowel syndrome in a UK population. Br J Surg 2000;87:1658–1663.

  29. 29.

    , . The epidemiology of hysterectomy and irritable bowel syndrome in a UK population. Int J Clin Pract 2000;54:647–650.

  30. 30.

    . The risk of abdominal surgery in irritable bowel syndrome. S Afr Med J 1986;70:91.

  31. 31.

    , , et al. Development of abdominal pain and IBS following gynecological surgery: a prospective, controlled study. Gastroenterology 2008;134:75–84.

  32. 32.

    , , et al. Irritable bowel syndrome and negative appendectomy: a prospective multivariable investigation. Gut 2007;56:655–660.

  33. 33.

    , , et al. Preoperative symptoms of irritable bowel syndrome predict poor outcome after laparoscopic cholecystectomy. Surg Endosc 2011;25:3379–3384.

  34. 34.

    , . Systematic review: abdominal and pelvic surgery in patients with irritable bowel syndrome. Aliment Pharmacol Ther 2003;17:997–1005.

  35. 35.

    , , et al. Prevalence of overlaps between GERD, FD and IBS and impact on health-related quality of life. J Gastroenterol Hepatol 2010;25:1151–1156.

  36. 36.

    , , et al. Anxiety and depression increase in a stepwise manner in parallel with multiple FGIDs and symptom severity and frequency. Am J Gastroenterol 2015;110:1038–1048.

  37. 37.

    , , et al. Symptom burden and consulting behavior in patients with overlapping functional disorders in the US population. United European Gastroenterol J 2016;4:413–422.

  38. 38.

    , , et al. Multiple functional gastrointestinal disorders linked to gastroesophageal reflux and somatization: a population-based study. Neurogastroenterol Motil 2017;29.

  39. 39.

    , , et al. Rome IV diagnostic questionnaires and tables for investigators and clinicians. Gastroenterology 2016;150:1481–1491.

  40. 40.

    , , et al. The Patient Health Questionnaire 12 Somatic Symptom scale as a predictor of symptom severity and consulting behaviour in patients with irritable bowel syndrome and symptomatic diverticular disease. Aliment Pharmacol Ther 2010;32:811–820.

  41. 41.

    , , . The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med 2002;64:258–266.

  42. 42.

    , , et alHow to Score and Interpret Single-Item Health Status Measures: A Manual for Users of the SF-8 Health Survey. Lincoln RI:Quality Metric, 2001.

  43. 43.

    Statistical Power Analysis For The Behavioral Sciences. Routledge, 1988..

  44. 44.

    , . Burden of digestive diseases in the United States part I: overall and upper gastrointestinal diseases. Gastroenterology 2009;136:376–386.

  45. 45.

    , , et al. Why do subjects with irritable bowel syndrome seek health care for their symptoms? Scand J Gastroenterol 2007;42:1194–1203.

  46. 46.

    , , et al. The relationship between somatisation and outcome in patients with severe irritable bowel syndrome. J Psychosom Res 2008;64:613–620.

  47. 47.

    , , et al. Visceral hypersensitivity in endometriosis: a new target for treatment? Gut 2012;61:367–372.

  48. 48.

    , , . Review article: bile acid diarrhoea—pathogenesis, diagnosis and management. Aliment Pharmacol Ther 2016;43:884–898.

  49. 49.

    , . Somatisation disorder in a British teaching hospital. Br J Clin Pract 1991;45:237–244.

  50. 50.

    . Irritable bowel syndrome and chronic pelvic pain. Obstet Gynecol Surv 1994;49:505–507.

  51. 51.

    , , et al. Irritable bowel syndrome and chronic pelvic pain: a population-based study. J Clin Gastroenterol 2010;44:696–701.

  52. 52.

    . Unnecessary abdominal and back surgery in irritable bowel syndrome: time to stem the flood now? Gastroenterology 2004;126:1899–1903.

  53. 53.

    . Avoiding unnecessary surgery in irritable bowel syndrome. Gut 2007;56:608–610.

  54. 54.

    , . Clinical and epidemiological differences in functional dyspepsia between the East and the West. Neurogastroenterol Motil 2016;28:167–174.

  55. 55.

    , , et al. Natural history of functional gastrointestinal disorders: a 12-year longitudinal population-based study. Gastroenterology 2007;133:799–807.

  56. 56.

    , , et al. Validation of the Rome III criteria for the diagnosis of irritable bowel syndrome in secondary care. Gastroenterology 2013;145:1262–1270.e1261.

  57. 57.

    , , et al. The Rome III criteria for the diagnosis of functional dyspepsia in secondary care are not superior to previous definitions. Gastroenterology 2014;146:932–940.

  58. 58.

    , , et al. Characteristics of functional bowel disorder patients: a cross-sectional survey using the Rome III criteria. Aliment Pharmacol Ther 2014;39:312–321.

Download references


The study was performed in accordance with the STROBE statement. The study was approved by the Institutional Review Board of the University of North Carolina, United States.

Author information


  1. Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

    • Imran Aziz
    • , Hans Törnblom
    •  & Magnus Simrén
  2. Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina, Chapel Hill, North Carolina, USA

    • Olafur S Palsson
    • , William E Whitehead
    •  & Magnus Simrén
  3. Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel

    • Ami D Sperber


  1. Search for Imran Aziz in:

  2. Search for Olafur S Palsson in:

  3. Search for Hans Törnblom in:

  4. Search for Ami D Sperber in:

  5. Search for William E Whitehead in:

  6. Search for Magnus Simrén in:

Competing interests

Guarantor of the article: Imran Aziz, MBChB, MD.

Specific author contributions: OSP and WEW contributed to the study design, questionnaire development, execution of survey, data processing, and manuscript editing. ADS contributed to the study design, questionnaire development, and manuscript editing. HT contributed to interpretation of data and manuscript editing. MS contributed to study design, interpretation of data and manuscript editing. IA analyzed the data and drafted the manuscript. All authors reviewed and approved the final version of the manuscript.

Financial Support: This study was supported by the Rome Foundation, NIDDK (grant RO1 DK31369), the Swedish Medical Research Council (grants 13409, 21691 and 21692), AFA Insurance, an unrestricted grant from Ferring Pharmaceuticals, and by the Faculty of Medicine, University of Gothenburg.

Potential competing interests: MS has received unrestricted research grants from Danone, and Ferring Pharmaceuticals, and served as a Consultant/Advisory Board member for AstraZeneca, Danone, Nestlé, Almirall, Allergan, Albireo, Glycom, and Shire, and as a speaker for Tillotts, Menarini, Takeda, Shire, Allergan, and Almirall. HT has served as Consultant/Advisory Board member for Almirall, Danone, and Shire. OSP has received salary support from a research grants from Takeda Pharmaceuticals and Salix Pharmaceuticals and from a consulting agreement with Ironwood Pharmaceuticals and an educational grant provided by Takeda Pharmaceuticals, and received a speaker honorarium in an educational programe supported by Ironwood Pharmaceuticals and Takeda Pharmaceuticals. WEW received research grants from Takeda, Ironwood, Salix, and the Rome Foundation; served as a consultant to Biomerica USA, Ono Pharmaceuticals and Ferring; and received unrestricted educational grants from Takeda and Ferring.

Corresponding author

Correspondence to Imran Aziz.

Supplementary information

Word documents

  1. 1.

    Supplementary Material

SUPPLEMENTARY MATERIAL is linked to the online version of the paper at http://www.nature.com/ajg