Rome IV Diagnosis Criteria for Functional Heartburn

Rome IV Functional Heartburn

Burning retrosternal discomfort or pain

No symptom relief with optimal antisecretory therapy

Absence of GERD (normal acid exposure on pH testing)

Absence of eosinophilic esophagitis

Absence of major esophageal motor disorder

Present for last 3 months with onset ≥6 months prior

Rome IV Assessment: Negative

Criteria Not Met

No criteria met for Rome IV functional heartburn.

Official Rome IV criteria for the diagnosis of functional heartburn.

Why Use

Helps to make a diagnosis of functional heartburn when appropriate workup, including assessment for pathologic GERD (pH study), eosinophilic esophagitis, and major esophageal motility disorders, is nondiagnostic. Helps to distinguish symptoms from other common disorders, such as GERD. Helps to guide management of symptoms once a diagnosis of functional heartburn is established.

When to Use

Patients presenting with recurrent retrosternal discomfort or pain for at least the past 6 months which are suggestive of functional heartburn. The diagnosis of functional heartburn should be made only after cardiac disease, gastroesophageal reflux disease, eosinophilic esophagitis, and major esophageal motility disorders have been excluded.

Formula

To fulfill the Rome IV criteria for functional heartburn, patient must have the following (for 3 months prior with symptom onset ≥6 months ago with a frequency of at least twice a week): Burning retrosternal discomfort or pain. No symptom relief despite optimal antisecretory therapy. Absence of evidence that gastroesophageal reflux (abnormal acid exposure and symptom reflux association) or EOE is the cause of symptoms. Absence of major esophageal motor disorders (achalasia/ EGJ outflow obstruction, diffuse esophageal spasm, jackhammer esophagus, absent peristalsis).

Pearls / Pitfalls

By definition, patients with functional heartburn do not experience relief of symptoms with optimal antisecretory therapy. Ambulatory reflux monitoring should be considered in patients without macroscopic evidence of gastroesophageal reflux disease (GERD) on upper endoscopy. Absence of abnormal acid exposure and symptom reflux association on pH testing is supportive of a diagnosis of functional heartburn. If esophageal manometry is performed, identification of a major esophageal motility disorder (e.g. achalasia, EGJ outflow obstruction, diffuse esophageal spasm, jackhammer esophagus, absent peristalsis) may explain the symptoms or coexist with functional heartburn.

Management

Management of functional heartburn may include: Tricyclic antidepressants (TCAs). Selective serotonin reuptake inhibitors (SSRIs). Serotonin noradrenergic reuptake inhibitors (SNRIs). Behavioral therapy (i.e. hypnosis). Consult AGA guidelines for further details.

Critical Actions

This calculator should only be used in patients who do not have signs or symptoms suggestive of a structural/mechanical, metabolic or systemic cause of their symptoms based on clinical history, physical exam and initial work-up. An esophageal pH study must show a normal amount of acid reflux and no symptom association with acid reflux.

Advice

If diagnostic criteria are not met (negative): Symptoms are unlikely to be caused by functional heartburn. Consider further assessment for other diseases, or a different functional GI disorder. If meets diagnosis (positive): Likely diagnosis of functional heartburn. Consider management as per current American Gastroenterological Association (AGA) Clinical Practice Update.