Navigating the maze of functional dyspepsia: emergence of a new entity, postprandial epigastric pain syndrome

Background & Aims: The Rome IV criteria subdivide functional dyspepsia (FD) into postprandial distress syndrome (PDS) with meal-related symptoms (early satiation and/or postprandial fullness) and epigastric pain syndrome (EPS) with meal-unrelated symptoms (epigastric pain and/or burning). We aimed to systematically assess the relationship of epigastric pain to meal ingestion in 4 independent FD databases. Methods: In total, 1337 patients with FD were included. Three cohorts (local, national, and international; total n = 971) completed a Rome IV symptom questionnaire, with additional questions on meal relationships. In 498 patients undergoing a standard gastric emptying breath test, we analyzed the evolution of symptoms during a 4-hour window. Patients were categorized as postprandial epigastric pain (pEPS), meal-unrelated epigastric pain (murEPS), and PDS symptoms with/without postprandial epigastric pain. Symptom profiles and demographics were compared between these categories. Results: Distribution for Rome IV PDS, EPS, and overlap was 896, 252, and 186. Postprandial epigastric pain without PDS symptoms (ie, pEPS) was present in approximately 40% of patients with EPS, whereas 60% had murEPS. Fifty percent of patients with PDS reported postprandial epigastric pain. Patient demographics were similar across categories. Overall, patients with PDS and postprandial epigastric pain had the most associated gastrointestinal symptoms, compared with pEPS, murEPS, or PDS without postprandial epigastric pain. Conclusion: In contrast to earlier characterization of EPS symptoms as purely meal-unrelated, we identified a relevant patient cohort with postprandial epigastric pain in the absence of PDS symptoms in 4 different cohorts. Further research is needed to determine the underlying pathophysiology and the response to different treatment approaches in these newly defined patient cohorts.