Background: Historically, functional dyspepsia (FD) has been subdivided into postprandial distress syndrome, PDS, with meal-related symptoms (i.e. early satiation or postprandial fullness) and epigastric pain syndrome, EPS, defined as meal-unrelated (i.e. epigastric pain or burning) according to the Rome criteria. However, currently available research has not addressed the extent to which epigastric pain is truly meal-unrelated.
Aim: To use four independent, prospectively collected FD databases to assess the relationship of epigastric pain to ingestion of a meal.
Methods: A total number of 1695 FD patients were included. The first cohort consisted of 495 clinical FD patients in a tertiary setting, who underwent standard gastric emptying breath test meal with simultaneous registration of perceived symptoms. Scores ranged 0-4 (with 0= absent, 4= unbearable and 2= bothersomeness/clinically relevant threshold). The second, international dataset consisted of 1080 DGBI patients from 16 centers (9 European / 7 Asian). The third and fourth dataset included respectively 223 and 494 Rome IV secondary care FD patients. These three cohorts completed an adapted Rome questionnaire, based on recall data, including questions on meal-related symptom occurrence. Those reporting postprandial epigastric pain (pEPS), meal-unrelated epigastric pain (murEPS), and PDS symptoms were compared with respect to the prevalence of a range of symptoms and demographic characteristics.
Results: In the first cohort, symptom assessment after a meal identified 317 patients with PDS symptoms. In patients not reporting PDS symptoms, 16.6% experienced pEPS and 11.4% murEPS. When comparing pure patient categories, EPS patients tended to have more epigastric burning (p=0.008), whereas PDS patients experienced more bloating (p<0.001). In the second cohort, 483 patients fulfilled Rome IV FD criteria (181 PDS; 133 EPS; 169 overlap PDS/EPS). Of EPS patients, 33.1% reported pEPS. Both epigastric burning and heartburn were significantly more experienced by EPS patients. In the third and fourth dataset, pEPS accounted for respectively 37.8% and 29.9% of pure EPS patients. Bloating and nausea were significantly more found in PDS patients, whereas heartburn was more prevalent in EPS patients. In all datasets age and weight did not significantly differ across patient categories. However, in the international study, BMI was significantly higher in murEPS compared to pEPS (p= 0.035).
Conclusion: In contrast to earlier characterization of EPS symptoms as being meal-unrelated, four large, independent datasets identify a substantial FD subgroup of patients with meal-related epigastric pain. Further research is needed to better characterize these patients, the underlying pathophysiology, and the response to treatment compared to meal-unrelated epigastric pain.

Karen Van Den Houte

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