Rome IV Diagnostic Criteria for Functional Dysphagia

Rome IV Functional Dysphagia

Sense of solid and/or liquid food sticking or passing abnormally through esophagus

Absence of structural disorder (e.g., stricture, web, ring)

Absence of mucosal disorder (e.g., 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 dysphagia.

Official Rome IV criteria for the diagnosis of functional dysphagia.

Why Use

Helps to make a diagnosis of functional dysphagia when appropriate workup is otherwise nondiagnostic. Helps to distinguish symptoms from other common disorders, such as complications of GERD (e.g. stricture) and major motility disorders. Helps to guide management of symptoms once a diagnosis of functional dysphagia is established.

When to Use

Patients presenting with symptoms of a recurrent sense of solid and/or liquid foods passing abnormally through the esophagus for at least 6 months, which are suggestive of functional dysphagia. The diagnosis of functional dysphagia should be made only after oropharyngeal mechanisms of dysphagia, structural lesions in the esophagus, gastroesophageal reflux disease, eosinophilic esophagitis, and major esophageal motility disorders have been excluded.

Formula

To fulfill the Rome IV criteria for functional dysphagia, patient must have the following (for 3 months prior with symptom onset ≥6 months ago with a frequency of at least once a week): Sense of solid and/or liquid foods sticking, lodging, or passing abnormally through the esophagus. Absence of evidence that esophageal mucosal or structural abnormality is the cause of the symptom. Absence of evidence that gastroesophageal reflux or EoE is the cause of the symptom. Absence of major esophageal motor disorders (achalasia/ EGJ outflow obstruction, diffuse esophageal spasm, jackhammer esophagus, absent peristalsis).

Pearls / Pitfalls

Oropharyngeal dysphagia should be excluded. Gastroesophageal reflux disease and eosinophilic esophagitis (EoE) should be excluded with an upper endoscopy (and biopsy to rule out EoE) and a trial of proton pump inhibitor therapy. Barium contrast studies may be considered to rule out structural abnormalities (e.g. esophageal stricture, web or paraesophageal hernia). In the absence of structural lesions by barium swallow or upper endoscopy, esophageal manometry is performed to exclude major motor disorders (e.g. achalasia, diffuse esophageal spasm). Borderline or minor motor disorders remain compatible with a diagnosis of functional dysphagia. In some cases, dysphagia may be due to subtle esophageal abnormalities such as a ring or web not seen by imaging. In this situation, empiric esophageal dilation may improve the dysphagia.

Management

Management of functional dysphagia may include: Proton pump inhibitors to treat complications of GERD when present. Empiric endoscopic esophageal dilation for subtle esophageal ring or stricture which may explain the dysphagia symptoms. Neuromodulators (i.e. tricyclic antidepressants).

Critical Actions

This calculator should only be used in patients after appropriate organic, systemic, and metabolic causes have been ruled out after careful investigation.

Advice

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