Rome IV Diagnostic Criteria for Reflux Hypersensitivity

Rome IV Reflux Hypersensitivity

Retrosternal symptoms (heartburn or chest pain)

Normal endoscopy (no mucosal abnormalities)

Absence of eosinophilic esophagitis

Absence of major esophageal motor disorder

Evidence of triggering by reflux events on impedance-pH testing despite normal acid exposure

Rome IV Assessment: Negative

Criteria Not Met

No criteria met for Rome IV reflux hypersensitivity.

Official Rome IV criteria for the diagnosis of reflux hypersensitivity.

Why Use

Helps to make a diagnosis of reflux hypersensitivity, in combination with ambulatory pH testing. Helps to distinguish symptoms from other common disorders, such as GERD, non-erosive esophageal reflux disease (NERD), and functional heartburn. Helps to guide management of symptoms once a diagnosis of reflux hypersensitivity is established.

When to Use

Patients presenting with recurrent retrosternal symptoms, such as heartburn and chest pain, for at least the past 6 months, which are suggestive of reflux hypersensitivity. The diagnosis of reflux hypersensitivity should be made only after eosinophilic esophagitis, major esophageal motility disorders, and abnormal acid exposure (on ambulatory monitoring) have been excluded.

Formula

To fulfill the Rome IV criteria for reflux hypersensitivity, patient must have the following (for 3 months prior with symptom onset ≥6 months ago with a frequency of at least twice a week): Retrosternal symptoms including heartburn and chest pain. Normal endoscopy and absence of evidence that EoE is the cause for symptoms. Absence of major esophageal motor disorders (achalasia/ EGJ outflow obstruction, diffuse esophageal spasm, jackhammer esophagus, absent peristalsis). Evidence of triggering of symptoms by reflux events despite normal acid exposure on pH or pH-impedance monitoring (response to antisecretory therapy does not exclude the diagnosis).

Pearls / Pitfalls

Response to antisecretory therapy does not rule out reflux hypersensitivity, but symptoms of reflux hypersensitivity may be refractory to antisecretory therapy. The diagnosis of reflux hypersensitivity hinges on the results of ambulatory pH monitoring, in which acid exposure is normal, but there is significant symptom-reflux association. 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 reflux hypersensitivity.

Management

Management of reflux hypersensitivity may include: Proton pump inhibitors (PPIs) or high dose H2 antagonists. Tricyclic antidepressants (TCAs). Selective serotonin reuptake inhibitors (SSRIs). Serotonin noradrenergic reuptake inhibitors (SNRIs).

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, which includes ambulatory pH monitoring.

Advice

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