AAAPT Diagnostic Criteria for Acute Abdominal and Peritoneal Pain After Surgery.

Abdominal and peritoneal pain after surgery is common and burdensome, yet the lack of standardized diagnostic criteria for this type of acute pain impedes basic, translational, and clinical investigations. The collaborative effort among the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks, American Pain Society, and American Academy of Pain Medicine Pain Taxonomy (AAAPT) provides a systematic framework to classify acute painful conditions. Using this framework, a multidisciplinary working group reviewed the literature and developed core diagnostic criteria for acute abdominal and peritoneal pain after surgery. In this report, we apply the proposed AAAPT framework to 4 prototypical surgical procedures resulting in abdominal and peritoneal pain as examples: cesarean delivery, cholecystectomy, colorectal surgical procedures, and pancreas resection. These diagnostic criteria address the 3 most common surgical procedures performed in the United States, capture diverse surgical approaches, and may also be applied to other surgical procedures resulting in abdominal and peritoneal pain. Additional investigation regarding the validity and reliability of this framework will facilitate its adoption in research that advances our comprehension of mechanisms, deliver better treatments, and help prevent the transition of acute to chronic pain after surgery in the abdominal and peritoneal region. PERSPECTIVE: Using AAAPT, we present key diagnostic criteria for acute abdominal and peritoneal pain after surgery. We provide a systematic classification using 5 dimensions for abdominal and peritoneal pain that occurs after surgery, in addition to 4 specific surgical procedures: cesarean delivery, cholecystectomy, colorectal surgical procedures, and pancreas resection.

Safety of Tiered-Dispatch for 911 Calls for Abdominal Pain.

INTRODUCTION: Many dispatch systems send Advanced Life Support (ALS) resources to patients complaining of abdominal pain even though the majority of these incidents require only Basic Life Support (BLS). With increasing 911-call volume, resource utilization has become more important to ensure that ALS resources are available for time-critical emergencies. In 2015, a large, urban fire department implemented an internally developed, tiered-dispatch system. Under this system, patients reporting a chief complaint of abdominal pain received the closest BLS ambulance dispatched alone emergency if located within three miles of the incident. The objective of this study was to determine the safety of BLS-only dispatch to abdominal pain by determining the frequency of time-sensitive events. METHODS: This was a retrospective review of electronic health records of one emergency medical service provider agency from May 2015-2018. Inclusion criteria were a chief complaint of abdominal pain from a first- or second-party caller, age over 15, and the patient was reported to be alert and breathing normally. The primary outcome was the prevalence of time-sensitive events, including cardiopulmonary resuscitation (CPR), defibrillation, or airway management. Secondary outcomes were hypotension (systolic blood pressure < 90 mmHg); or a prehospital 12 lead-electrocardiogram (ECG) demonstrating ST-elevation myocardial infarction (STEMI) criteria or a wide complex arrhythmia. Descriptive statistics were used. RESULTS: During the study period, there were 1,220,820 EMS incidents, of which 33,267 (2.72%) met inclusion criteria. The mean age was 49.9 years (range 16-111, standard deviation [SD] 19.6); 14,556 patients (56.2%) were female. Time-sensitive events occurred in seven cases (0.021%), mean age was 75.3 years (range 30-86, SD18.7); 85.7% were female. Airway management was required in seven cases (0.021%), CPR in six cases (0.018%), and defibrillation in one case (0.003%). Two of the seven (28.6%) cases involved dispatch protocol deviations. Hypotension was present in 240 (0.72%) cases; six (0.018%) cases had 12-lead ECGs meeting STEMI criteria; and no cases demonstrated wide complex arrhythmia. CONCLUSION: Among adult 911 patients with a dispatch chief complaint of abdominal pain, time-sensitive events were exceedingly rare. Dispatching a BLS ambulance alone appears to be safe.

Abdominal Physical Signs and Medical Eponyms: Movements and Compression.

BACKGROUND: Prior to the advent of modern imaging techniques, maneuvers were performed as part of the physical examination to further assess pathological findings or an acute abdomen and to further improve clinicians' diagnostic acumen to identify the site and cause of disease. Maneuvers such as changing the position of the patient, extremity, or displacing through pressure a particular organ or structure from its original position are typically used to exacerbate or elicit pain. Some of these techniques, also referred to as special tests, are ascribed as medical eponym signs. DATA SOURCES: PubMed, Medline, online Internet word searches, textbooks and references from other source text. PubMed was searched using the Medical Subject Heading (MeSH) of the name of the eponyms and text words associated with the sign. CONCLUSION: These active and passive maneuvers of the abdomen, reported as medical signs, have variable performance in medical practice. The lack of diagnostic accuracy may be attributed to confounders such as the position of the organ, modification of the original technique, or lack of performance of the maneuver as originally intended.

Painful or Mild-Pain Constipation? A Clinically Useful Alternative to Classification as Irritable Bowel Syndrome with Constipation Versus Functional Constipation.

PURPOSE: Abdominal pain is not used to characterize constipated patients. This study aimed to compare clinical, psychological, and physiological features in patients with IBS-constipation (IBS-C) with those in patients with functional constipation (FC) according to the intensity of abdominal pain. METHODS: All patients filled a standard Rome III questionnaire. In addition, they indicated the intensity of constipation, diarrhea, bloating, and abdominal pain on a 10-point Likert scale, and their stool form with the Bristol Stool Form Scale. Anxiety and depression were assessed with the Beck Depression Inventory and the State-Trait Anxiety Inventory. Physiological evaluation included anorectal manometry and total and segmental colonic transit time. MAIN RESULTS: A total of 546 consecutive patients, 245 with IBS-C and 301 with FC, were included. Painful constipation (PFC) was found by cluster analysis and subsequently defined as having a value over four on the Likert scale for abdominal pain. PFC was found in 67% of IBS-C patients and in 22% of FC patients. PFC patients have digestive disorders with greater frequency and report higher levels of constipation and bloating, despite similar stool form. They have higher scores of depression, state and trait anxiety, and shorter terminal transit time than mild-pain constipated patients. Compared to IBS-C patients, PFC patients report higher levels of abdominal pain (P < 0.001). Psychological and physiological parameters were similar in PFC and IBS-C patients. CONCLUSION: Painful constipation and mild-pain constipation could be an alternative way to identify constipated patients than using the diagnosis of IBS-C and FC for clinical evaluation and drug studies.

The latent structure of the functional dyspepsia symptom complex: a taxometric analysis.

OBJECTIVES: Rome III introduced a subdivision of functional dyspepsia (FD) into postprandial distress syndrome and epigastric pain syndrome, characterized by early satiation/postprandial fullness, and epigastric pain/burning, respectively. However, evidence on their degree of overlap is mixed. We aimed to investigate the latent structure of FD to test whether distinguishable symptom-based subgroups exist. METHODS: Consecutive tertiary care Rome II FD patients completed the dyspepsia symptom severity scale. Confirmatory factor analysis (CFA) was used to compare the fit of a single factor model, a correlated three-factor model based on Rome III subgroups and a bifactor model consisting of a general FD factor and orthogonal subgroup factors. Taxometric analyses were subsequently used to investigate the latent structure of FD. KEY RESULTS: Nine hundred and fifty-seven FD patients (71.1% women, age 41 ± 14.8) participated. In CFA, the bifactor model yielded a significantly better fit than the two other models (χ² difference tests both p < 0.001). All symptoms had significant loadings on both the general and the subgroup-specific factors (all p < 0.05). Somatization was associated with the general (r = 0.72, p < 0.01), but not the subgroup-specific factors (all r < 0.13, p > 0.05). Taxometric analyses supported a dimensional structure of FD (all CCFI<0.38). CONCLUSIONS AND INFERENCES: We found a dimensional rather than categorical latent structure of the FD symptom complex in tertiary care. A combination of a general dyspepsia symptom reporting factor, which was associated with somatization, and symptom-specific factors reflecting the Rome III subdivision fitted the data best. This has implications for classification, pathophysiology, and treatment of FD.

The Heidelberg Appendicitis Score Simplifies Identification of Pediatric Appendicitis.

OBJECTIVE: To identify the factors that facilitate the diagnosis of pediatric appendicitis. METHODS: Institutionally approved retrospective, single center analysis of all patients with acute abdominal pain was done. Medical history, symptoms, laboratory and radiologic findings of all children presenting with abdominal pain were evaluated. To identify the best predictors, uni- and multi-variate analysis were used. RESULTS: In 2 years, 431 patients fulfilled the inclusion criteria. Data was complete in all subjects. Of these, 156 (36.2 %) suffered from appendicitis. The best discriminators for appendicitis were clinical and ultrasound features. The four best factors were identified by CART analysis (continuous abdominal pain, tenderness on the right lower quadrant, rebound tenderness and conspicuous ultrasound) and combined to the Heidelberg Appendicitis score. A positive score (>3 features) is highly predictive for acute appendicitis (PPV 89.3 %, NPV 94.9 %) and includes all cases of perforated appendicitis. CONCLUSIONS: It is possible to predict acute appendicitis in children. The decision making process can be simplified by the proposed Heidelberg Appendicitis score, which is comprised of four factors. It has great potential to facilitate and accelerate the diagnosis of pediatric appendicitis.

Sphincter of Oddi dysfunction Type III: New studies suggest new approaches are needed.

Sphincter of Oddi dysfunction (SOD) has been classified into three types based upon the presence or absence of objective findings including liver test abnormalities and bile duct dilatation. Type III is the most controversial and is classified as biliary type pain in the absence of any these objective findings. Many prior studies have shown that the clinical response to endoscopic therapy is higher based upon the presence of these objective criteria. However, there has been variable correlation of the manometry findings to outcome after endoscopic therapy. Nevertheless, manometry and sphincterotomy has been recommended for Type III patients given the overall response rate of 33%, although the reported response rates are highly variable. However, all of the prior data was non-blinded and non-randomized with variable follow-up. The evaluating predictors in SOD study - a prospective randomized blinded sham controlled one year outcome study showed no correlation between manometric findings and outcome after sphincterotomy. Furthermore, patients receiving sham therapy had a statistically significantly better outcome than those undergoing biliary or dual sphincterotomy. This study calls into question the whole concept of SOD Type III and, based upon prior physiologic studies, one can suggest that SOD Type III likely represents a right upper quadrant functional abdominal pain syndrome and should be treated as such.

Ranking of dental and somatic pain sensations among paediatric dental patients.

BACKGROUND: Children suffer from somatic and dental pain, which may interfere with their everyday life. Pain self-report tools are available for children. Research is needed to better understand the perception of dental pain in comparison with pain in other organs. AIM: To investigate relations between the perceptions of dental and somatic pain complaints among school-age children. DESIGN: One hundred and two children, aged 7-17 years (mean age, 11.5 ± 2.65 years), completed questioners regarding their somatic and dental: 1. Memory pain rank (MPR) and 2. Wong-Baker FACES Pain Rating Scale (FRS). RESULTS: Children reported increased dental pain after school in both scales (P = 0.015 in MPR). In both MPR and FRS, the pattern of pain ranking was similar: Abdominal pain was scored highest (2.75 ± 1.4 and 1.56 ± 1.63, respectively), followed by headache, ear, dental and TMJ (Temporomandibular joint). CONCLUSION: There was a strong correlation between pain perception and current pain scores in every organ. Somatic pain, namely head, abdomen and ears, was ranked significantly higher than dental and TMJ pain. School-aged children rank current pain and pain experience significantly lower while they are pre-occupied (school time) in comparison with times when they are less busy (after school time).

The predictive value of pre-operative symptoms including upper gastrointestinal endoscopy before laparoscopic cholecystectomy for elective symptomatic cholecystolithiasis.

BACKGROUND: It has always been a challenge to distinguish between upper gastrointestinal symptoms due to gall stones or any other causes. The persistence of abdominal symptoms even after cholecystectomy is highly discouraging for surgeons. OBJECTIVE: To evaluate the value of preoperative (UGE) as a routine investigative tool in patients with gall stone disease and to assess the outcome of cholecystectomy in patients with gallstones on preoperative abdominal symptoms. METHODS: This is a prospective study conducted on 96 cases at the Department of Surgery, Dhulikhel Hospital among ultrasonographically proven gall bladder stones irrespective of age and sex. After the examination, all the patients were subjected to UGE, and biopsy were obtained for histopathology if required. The statistical analysis were performed using spss version 16. RESULTS: Out of total patients, 84(87.5%) were females and 12(12.5%) were males with a M: F ratio of 1:7. Both the sexes were comparable in age groups. Out of total 96 patients, 53(55.2%) presented with typical pain and 43(44.8%) presented with atypical pain. All the patients were subjected to upper gastrointestinal endoscopy (UGE) and 53(55.2%) had normal findings and 43(44.8%) had various lesions. Patients with typical pattern of pain had normal endoscopic findings and those with atypical pain had pathology in upper gastroendoscopy (p<0.001). Serious pathology resulting to change of the planned treatment was found in three cases (3.12%). Among them two had gastric carcinoma and one had active peptic ulcer disease. The relief rate after the cholecystectomy was significant in patients with typical pain than among those with atypical pain (p<0.001). The commenest post cholecystectomy symptoms were heart burn (10%), abdominal discomfort (9%) and dyspepsia (7%). CONCLUSION: Presence of atypical pain in patients with gall stones is highly likely to have other coexisting upper gastrointestinal pathologies. Hence, upper gastrointestinal endoscopy prior to elective cholecystectomy in patients with gall stones can be clinically helpful.

Dolor abdominal crónico en pediatría / Chronic abdominal pain in children

Chronic Abdominal Pain (CAP) in children is a common cause to seek medical care. This paper summarizes current physiological and biochemical concepts that help in understanding the symptomatology. A review of the main etiological causes connected to CAP is offered, as well as a systematic process to evaluate and diagnose each. Recommendations for management and referral are provided.

El dolor abdominal crónico en niños es una causa común de consulta médica. El presente trabajo resume los conceptos fisiológicos y bioquímicos actuales que apuntan hacia el cabal entendimiento de la sintomatología. En este artículo se presenta una revisión de las principales causales etiológicas asociadas al dolor abdominal crónico, como asimismo un proceso sistemático para evaluar y diagnosticar cada caso. Igualmente, se proporcionan recomendaciones para su manejo y derivación a especialista.

Identifying symptom groups from Emergency Department presenting complaint free text using SNOMED CT.

Patients presenting to Emergency Departments may be categorised into different symptom groups for the purpose of research and quality improvement. The grouping is challenging due to the variability in the way presenting complaints are recorded by clinical staff. This work proposes analysis of the presenting complaint free-text using the semantics encoded in the SNOMED CT ontology. This work demonstrates a validated prototype system that can classify unstructured free-text narratives into patient's symptom group. A rule-based mechanism was developed using variety of keywords to identify the patient's symptom group. The system was validated against the manual identification of the symptom groups by two expert clinical research nurses on 794 patient presentations from six participating hospitals. The comparison of system results with one clinical research nurse showed 99.3% sensitivity; 80.0% specificity and 0.9 F-score for identifying "chest pain" symptom group.

La gastroenterología pediátrica en Colombia / Pediatric gastroenterology in Colombia

Los antecedentes, la historia y la práctica de la gastroenterología pediátrica en Latinoamérica y otros países ya ha sido relatada previamente. Son pocos los estudios colombianos que muestran la estadística de las principales entidades digestivas que afectan a los niños colombianos. Las principales universidades públicas del país cuentan con la asignatura de gastroenterología pediátrica dentro de su pensum académico. Tres sociedades agremian a la mayoría de los gastroenterólogos pediatras colombianos: dos nacionales y una internacional. Cuatro congresos colombianos, han sido realizados en nuestro país. Cuatro libros y un suplemento del Journal of Pediatric Gastroenterology and Nutrition han sido editados por gastroenterólogos pediatras del país, así como algunos artículos a manera de artículos originales, revisiones de tema y resúmenes de trabajos libres han sido publicados en revistas internacionales.

The background, history and practice of pediatric gastroenterology in Latin America and other countries has been reported previously. Few studies about colombian statistics showing the main entities that affect the digestive colombian children. The main public universities in the country have the subject of pediatric gastroenterology in their academic curriculum. There are three societies for pediatric gastroenterology in Colombia: two domestic and one international. Four colombian congress have been made in our country. Four books and a supplement of the Journal of Pediatric Gastroenterology and Nutrition has been edited by the nation's pediatric gastroenterologists and a few ítems by way of original articles, reviews the subject and free abstracts have been published in international journals.

Abdominal migraine: an under-diagnosed cause of recurrent abdominal pain in children.

OBJECTIVE: Our objective was to demonstrate that, despite recognition by both the gastroenterology and headache communities, abdominal migraine (AM) is an under-diagnosed cause of chronic, recurrent, abdominal pain in childhood in the USA. BACKGROUND: Chronic, recurrent abdominal pain occurs in 9-15% of all children and adolescents. After exclusion of anatomic, infectious, inflammatory, or other metabolic causes, "functional abdominal pain" is the most common diagnosis of chronic, idiopathic, abdominal pain in childhood. Functional abdominal pain is typically categorized into one, or a combination of, the following 4 groups: functional dyspepsia, irritable bowel syndrome, AM, or functional abdominal pain syndrome. International Classification of Headache Disorders--(ICHD-2) defines AM as an idiopathic disorder characterized by attacks of midline, moderate to severe abdominal pain lasting 1-72 hours with vasomotor symptoms, nausea and vomiting, and included AM among the "periodic syndromes of childhood that are precursors for migraine." Rome III Gastroenterology criteria (2006) separately established diagnostic criteria and confirmed AM as a well-defined cause of recurrent abdominal pain. METHODS: Following institutional review board approval, a retrospective chart review was conducted on patients referred to an academic pediatric gastroenterology practice with the clinical complaint of recurrent abdominal pain. ICHD-2 criteria were applied to identify the subset of children fulfilling criteria for AM. Demographics, diagnostic evaluation, treatment regimen and outcomes were collected. RESULTS: From an initial cohort of 600 children (ages 1-21 years; 59% females) with recurrent abdominal pain, 142 (24%) were excluded on the basis of their ultimate diagnosis. Of the 458 patients meeting inclusion criteria, 1824 total patient office visits were reviewed. Three hundred eighty-eight (84.6%) did not meet criteria for AM, 20 (4.4%) met ICHD-2 formal criteria for AM and another 50 (11%) had documentation lacking at least 1 criterion, but were otherwise consistent with AM (probable AM). During the observation period, no children seen in this gastroenterology practice had received a diagnosis of AM. CONCLUSION: Among children with chronic, idiopathic, recurrent abdominal pain, AM represents about 4-15%. Given the spectrum of treatment modalities now available for pediatric migraine, increased awareness of cardinal features of AM by pediatricians and pediatric gastroenterologists may result in improved diagnostic accuracy and early institution of both acute and preventative migraine-specific treatments.

Subtypes of irritable bowel syndrome based on abdominal pain/discomfort severity and bowel pattern.

INTRODUCTION: Irritable bowel syndrome (IBS) has traditionally been classified by stooling pattern (e.g., diarrhea-predominant). However, other patterns of symptoms have long been recognized, e.g., pain severity. Our objective was to examine the utility of subtyping women with IBS based on pain/discomfort severity as well as predominant bowel pattern. METHODS: Women (n = 166) with IBS completed interviews, questionnaires, and kept a diary for 28 days. Rome II questionnaire items eliciting the past year recall of hard and loose stools, and frequency and severity of abdominal pain or discomfort were used to classify participants into six subtypes-three bowel pattern categories by two pain/discomfort severity categories. Concordance of these subtypes with corresponding diary items was examined. Analysis of variance (ANOVA) tested the relationship of bowel pattern and pain categories to measures of quality of life and symptoms. RESULTS: There is moderate congruence of the retrospective classification of bowel pattern and pain/discomfort severity subtypes with prospectively reported stool frequency and consistency and pain severity. Quality of life, impact of IBS on work and daily activities, and cognitive beliefs about IBS differed significantly based on abdominal pain/discomfort category but not on predominant bowel pattern. There is evidence of an interaction, with the effect of pain severity being strong in the IBS-diarrhea and IBS-mixed groups, but this was absent in the IBS-constipation group. Similar results hold for most diary symptoms, except for those directly related to bowel pattern. CONCLUSIONS: Overall, the distress of IBS is more strongly related to the severity of abdominal pain/discomfort than is the predominant stool pattern in patients with IBS. Categorizing IBS patients by abdominal pain/discomfort severity in conjunction with predominant bowel pattern may be useful to clinicians and researchers in developing more effective management.

The interpretation of Rome III criteria and method of assessment affect the irritable bowel syndrome classification of children.

BACKGROUND: Paediatric classification of irritable bowel syndrome (IBS) is complicated by the potential discrepancy between parent and child report and by the interpretation of pain-stool relations in the Rome III classification system. AIM: To compare IBS classification by diary and by child and parent respondents. METHODS: Children (ages 7-10 years, n = 90) with recurrent abdominal pain and their parents completed IBS symptom questionnaires and 2-week pain and stool diaries. Diaries were coded with two algorithms, one defining stool changes individually and one defining changes normatively. Proportions of dichotomous classifications (IBS vs. not IBS) between pairs of classification methods/respondents were evaluated using Chi-squared tests (χ²) to determine whether coding methods were significantly related, the degree of inclusiveness, and whether differences in classification were randomly distributed. RESULTS: Individual and normative diary classifications were congruent in 62% of cases, but the individual method classified more children with IBS, 53% vs. 18%. Parent and child questionnaire reports were not correlated. The normative diary classifications and parent questionnaire were the most congruent pair of methods (76% of cases). CONCLUSIONS: Poor congruence among methods suggests that Rome III IBS criteria need better specification, and efforts to improve parent-child agreement are necessary.

Lower abdominal wall pain and contusion in single-incision laparoscopic cholecystectomy.

There is a surge in interest in single-incision laparoscopic surgery in the recent years. Due to entry of all the ports and instruments from the same incision and obliquity of the instruments, the lowermost port exerts repeated pressure on the infraumbilical abdominal wall. We are reporting 2 cases of single-incision laparoscopic surgery cholecystectomy who presented with lower abdominal pain and contusion in the post operative period.

Protocolos de atención de enfermedades quirúrgicas más frecuentes en adultos / Care protocols most common surgical diseases in adults

El Gobierno de Reconciliación y Unidad Nacional a través del Ministerio de Salud, presente el siguiente documento Protocolos de atención de enfermedades quirúrgicas más frecuentes en adultos, que es una recopilación de los servicios de los Hospitales Alemán Nicaraguense y Antonio Lenin Fonseca quienes iniciaron revisión, actualización y elaboración de guías clínicas de las principales patologías atendidas en los servicios. Este trabajo se base en la búsqueda de la unificación de criterios y la mejor utilización de recursos en función de brindar un servicio eficaz y de calidad para nuestros usuarios y usuarias...

[Rome III classification of functional gastrointestinal disorders in children with chronic abdominal pain]. / Ocena przydatnosci III klasyfikacji rzymskiej w diagnostyce przewleklych czynnosciowych bólów brzucha u dzieci.

BACKGROUND: The updated Rome III Classification of paediatric functional gastrointestinal disorders (FGIDs) associated with abdominal pain comprises: functional dyspepsia (FD), irritable bowel syndrome (IBS), abdominal migraine, functional abdominal pain (FAP), functional abdominal pain syndrome (FAPS). THE AIM OF THIS STUDY: To assess the value of the Rome criteria in identifying FGIDs in children with chronic abdominal pain. MATERIAL AND METHODS: The study group consisted of 439 consecutive paediatric patients (192 boys and 247 girls) aged 4-18 years (mean age was 11.95 +/- 3.89 years) referred to the Paediatric Gastroenterology Department at Medical University of Lodz from January 2008 to June 2009 for evaluation of abdominal pain of at least 2 months' duration. After exclusion of organic disease children suspected of functional chronic abdominal pain were categorized with the use of Rome III criteria of FGIDs associated with abdominal pain (H2a-H2d1) and the Questionnaire on Paediatric Gastrointestinal Symptoms (with the permission of doctor L. S. Walker). The patients with known nonabdominal organic disease, chronic illness or handicap were excluded. RESULTS: In 161 patients (36.58%) organic etiology was confirmed. Of the 278 children (63.42%) with functional chronic abdominal pain, 228 (82.02%) met the Rome III criteria for FGIDs associated with abdominal pain (FD, 15.5%; IBS, 21.6%; abdominal migraine, 5%; FAP 24.5%; FAPS, 15.9%). Fifty cases (17.98%) did not fulfill the criteria for subtypes of abdominal pain-related FGIDs--mainly due to different as defined by Rome III criteria (at least once per week) frequency of symptom presentation. CONCLUSIONS: (1) In the authors'investigations FGIDs was the most frequent cause of chronic abdominal pain in children. (2) The significant number of children with nonclassified FGIDs implies the need to modify the diagnostic criteria of Rome III classification concerning the prevalence of symptoms.