Rome IV Diagnostic Criteria for Functional Chest Pain

Rome IV Functional Chest Pain

Retrosternal chest pain or discomfort

No associated esophageal mucosal abnormality

No associated esophageal motor disorder

No GERD as explanation

Present for last 3 months with onset ≥6 months prior

Rome IV Assessment: Negative

Criteria Not Met

No criteria met for Rome IV functional chest pain.

Official Rome IV criteria for the diagnosis of functional chest pain.

Why Use

Helps to make a diagnosis of functional chest pain when cardiac causes are ruled out and appropriate workup (which may include assessment for GERD, eosinophilic esophagitis, and major esophageal motility disorders) is nondiagnostic. Helps to guide management of symptoms once a diagnosis of functional chest pain is established.

When to Use

Patients presenting with recurrent, unexplained chest pain or discomfort for at least the past 6 months which are suggestive of functional chest pain. The diagnosis of functional chest pain should only be made after cardiac causes are ruled out and esophageal workup is otherwise non-diagnostic.

Formula

To fulfill the Rome IV criteria for functional chest pain, patient must have the following (for 3 months prior with symptom onset ≥6 months ago with a frequency of at least once a week): Retrosternal chest pain or discomfort; cardiac causes should be ruled out. Absence of associated esophageal symptoms, such as heartburn and dysphagia. Absence of evidence that gastroesophageal reflux or eosinophilic esophagitis are the cause of the symptom. Absence of major esophageal motor disorders (achalasia/ EGJ outflow obstruction, diffuse esophageal spasm, jackhammer esophagus, absent peristalsis).

Pearls / Pitfalls

Cardiac causes must be excluded. Given the high prevalence of gastroesophageal reflux disease (GERD) with non-cardiac chest pain, a trial of high dose proton pump inhibitor (PPI) therapy can be considered to determine whether GERD may trigger symptoms. Ambulatory reflux monitoring can be considered in patients who do not respond to PPI therapy. If upper endoscopy is pursued, biopsies should be obtained to assess for eosinophilic esophagitis. Once GERD has been ruled out, esophageal manometry should be considered to assess for presence of a major esophageal motility disorder. Psychiatric diagnoses (e.g. anxiety and depression) are common in functional chest pain.

Management

Management of functional chest pain may include: Tricyclic antidepressants (TCAs). Selective serotonin reuptake inhibitors (SSRIs). Serotonin noradrenergic reuptake inhibitors (SNRIs). Trazodone. Behavioral therapy (e.g. cognitive behavioral therapy [CBT], hypnosis).

Critical Actions

This calculator should only be used in patients who do not have signs or symptoms suggestive of cardiac disease, or a structural/mechanical, metabolic or systemic cause of their symptoms based on clinical history, physical exam and initial work-up.

Advice

If diagnostic criteria are not met (negative): Symptoms are unlikely to be caused by functional chest pain. Consider further assessment for other diseases or a different functional GI disorder. If meets diagnosis (positive): Likely diagnosis of functional chest pain.