Functional Dyspepsia and Accumulation (積) in Classical Texts: Overlapping Discomfort, Different Criteria

Before Reading Post-Meal Discomfort Through Two Names

Early satiation that makes it difficult to continue after only a few bites, bothersome fullness after a meal, and epigastric pain or burning are all symptoms that Rome IV asks about when assessing functional dyspepsia. The names of the symptoms alone, however, do not settle the assessment. On routine evaluation, there must be no evidence of structural disease likely to explain them, and the specified duration requirements must also be met.[1]

When this kind of post-meal discomfort is read alongside 痰積, 食積, and 積聚 in the classical texts verified here, we cannot immediately conclude that they describe the same disease in different words. These texts also attend to observations outside the Rome IV symptom criteria, including pulse findings, diarrhea, palpable form, and multiple locations across the chest, flanks, and abdomen.[2-4] Symptom overlap and identical diagnostic criteria are two different claims.

This article compares only how the Rome IV criteria and the classical passages examined here organize observations. It does not evaluate contemporary damjeok diagnostic criteria or their validity, clinical utility, or the genealogy linking classical terms to contemporary damjeok. The materials reviewed for this article also contain no data in which the Rome IV criteria and contemporary damjeok criteria were applied to the same individuals. They therefore cannot support estimates of how much the patient populations overlap, how consistently classifications agree, or how prevalence, diagnostic accuracy, prognosis, or treatment response differ.

What Rome IV Actually Asks

The Rome IV criteria for functional dyspepsia require one or more of four ‘bothersome’ symptoms: postprandial fullness, early satiation, epigastric pain, or epigastric burning. Here, ‘bothersome’ means severe enough to affect usual activities. The criteria must have been fulfilled for the preceding three months, with symptom onset at least six months before diagnosis. There must also be no evidence of structural disease likely to explain the symptoms, including disease detectable at upper endoscopy.[1]

Rome IV divides this symptom pattern into two categories. Postprandial distress syndrome (PDS) is defined by bothersome postprandial fullness that affects usual activities and/or early satiation that prevents completion of a regular-size meal, on at least three days per week. Epigastric pain syndrome (EPS) is defined by bothersome epigastric pain and/or burning that affects usual activities on at least one day per week. The two categories may overlap.[1]

Nausea, belching, and postprandial epigastric bloating may also occur, but they are not placed on the same footing as the core diagnostic symptoms. Persistent vomiting warrants consideration of another disorder, and symptoms relieved by passage of stool or gas are generally not counted as part of dyspepsia.[1] Even within the everyday phrase ‘epigastric discomfort,’ decisions about what to include and exclude change the diagnostic scope.

These criteria organize the types, frequency, and duration of symptoms and the absence of structural disease that could explain them.[1] They include no item that determines a specific mechanism, so meeting the criteria does not by itself identify the cause of the symptoms. When the criteria are compared with the selected classical language of accumulation, symptom classification must therefore remain separate from causal explanation. Above all, comparison with another diagnostic language cannot erase the requirement that there be no structural disease likely to explain the symptoms.

Classical Accumulation (積) Was Not a Single Gastrointestinal Symptom

In an electronic transcription with normalized character forms of Zhu Zhenheng's (朱震亨) Yuan-period Jingui Gouxuan (《金匱鉤玄》), 痰積 is not organized as a single modern symptom cluster. It appears separately in the sections on ‘Diarrhea (泄瀉)’ and ‘Vertigo (頭眩)’: the former distinguishes phlegm and food accumulation, among other contexts of diarrhea, while the latter associates an excess pulse finding in the right hand with 痰積.[2] In these two passages, 痰積 does not refer only to postprandial fullness or early satiation.

The ‘Internal Causes—Accumulations and Gatherings (內因類·積聚)’ section of Zabing Guangyao (《雜病廣要》), which the electronic text labels as ‘compiled by Tanba Genkan (丹波元堅) of Japan,’ organizes observations differently. It distinguishes a form that can be verified by pressing within the abdomen, one that shifts when pushed, one located toward the flank, and one bound hard and deep within. It then describes the hard, immobile type as 積 and the type that gathers and disperses, with distension or pain that comes and goes, as 聚.[3] Unlike Rome IV, which counts the frequency of four cardinal symptoms, this account distinguishes by form, movement, location, and response to pressure.

In an electronic text with Korean interpretations of the Miscellaneous Diseases section (雜病篇) of Donguibogam (《東醫寶鑑》), compiled by Heo Jun in Joseon, the section on the ‘Meaning of the Dochang Method (倒倉之義)’ describes long-standing phlegm becoming sticky like glue, clinging within the chest, and becoming entangled outside the intestines and stomach; it discusses 痰積 alongside paralysis, consumptive illness, abdominal distension, and dysphagia.[4] This is the language in which the text explained illness, not a report confirming a modern anatomical lesion. The passage shows one instance in which 痰積 was used across a wider range of locations and illness presentations, not only postprandial epigastric discomfort.

The starting point for this comparison is limited to particular electronic texts of three works and the section titles and line locations cited above. The materials reviewed here do not include the exact editions, volume, page or folio details, collations of character variants, histories of later reception, or links to facsimiles. The Korean renderings given here follow the access translations and interpretations used for this review and were not collated against other editions or translations. These passages therefore show how 積, 聚, and 痰積 in classical texts distinguished pulse, palpation, location, course, and a range of illness presentations, but they do not establish a definition of contemporary damjeok or a genealogy leading to it.[2-4]

Where Symptoms Overlap and Criteria Diverge

Some symptom terms overlap between Rome IV and the classical passages selected here. Rome IV notes that nausea, excessive belching, and postprandial epigastric bloating may accompany functional dyspepsia. A passage in Donguibogam concerning food accumulation (食積) and phlegm-fluid (痰飮) also lists 痞滿, nausea, belching, and acid regurgitation.[1,4] The classical passage, however, does not use postprandial timing or interference with usual activities as a diagnostic threshold, and it includes presentations beyond the scope of Rome IV functional dyspepsia, such as jaundice and the historical category 食瘧 (‘food malaria’). Even when the same symptom term appears on both sides, its diagnostic role differs.

The differences become clearer when structure, location, and examination methods are considered. Rome IV uses epigastric symptoms and duration as positive criteria and requires that there be no evidence of structural disease likely to explain those symptoms.[1] The selected classical records, by contrast, distinguish multiple locations in the chest, flanks, and abdomen; forms and movement identified by pressure; and pulse findings.[2,3] A palpable form or pulse characteristic is not another name for postprandial fullness or early satiation, nor does it replace Rome IV's structural-disease exclusion requirement.

Time and the significance of defecation also diverge. Rome IV requires symptoms during the preceding three months, onset at least six months before diagnosis, and minimum weekly frequencies.[1] In Zabing Guangyao, 聚 is described as starting and stopping, at times coming and going, while Jingui Gouxuan treats pain that diminishes after diarrhea as a clue for distinguishing 食積.[2,3] Rome IV generally does not count symptoms that improve after passage of stool or gas as part of dyspepsia.[1] A feature used as a distinguishing sign in one may signal that the symptom falls outside the scope of the other.

Overlapping terms such as nausea, belching, and fullness can therefore begin a comparison, but they do not make the two classifications the same. The passages cited here support only this conclusion: Rome IV and the selected classical records of 痰積, 食積, and 積聚 address some similar forms of discomfort while setting their boundaries through different symptoms, durations, locations, and examination findings.[1-4] These materials alone do not allow us to assess the criteria, genealogy, validity, or clinical utility of contemporary damjeok, nor can they turn points of symptom overlap into diagnostic equivalence or a single shared mechanism.

What Must Be Measured Before Calling Them the Same

To study this difference comparatively, the design must first avoid translating one language into and substituting it for the other. Future studies could assess the same participants at the same time point and test a method that records the Rome IV symptom and duration criteria and separately defined examination findings as independent items. The classical passages verified here, however, do not validate the construct, procedures, inter-rater reliability, or clinical utility of a contemporary damjeok examination. What and how to measure must therefore first be defined and validated in a separate study, and the design must not infer one diagnosis or mechanism from the results obtained under the other framework. Only then can we ask whether the two observations occur together in the same person at the same time.[1-4]

Before that sequence comes a safety boundary. Functional dyspepsia includes the requirement that there be no evidence of structural disease likely to explain the symptoms.[1] Neither describing the symptoms as damjeok nor noting findings on abdominal examination shows that this requirement has been met, and neither substitutes for the necessary evaluation. The evaluation needed depends on the clinical context, but applying another diagnostic language does not make this requirement disappear.

The next study should begin by synchronizing its observations rather than by first declaring that ‘the two are the same.’ In the same participants and over the same period, it should concurrently record symptom frequency and duration and separately defined examination findings, and it should first validate what each method measures and whether its results are reproducible across evaluators. Only then can the degree to which the two results co-occur be calculated. Even if they co-occur, whether one causes the other remains a separate question requiring validation.[1-4]

The conclusion we can draw now is limited. Rome IV and the passages on 痰積, 食積, and 積聚 selected here share some symptom terms, but this does not provide grounds for combining their different criteria and observations into a single diagnosis.[1-4] This conclusion is not an evaluation of the definition, genealogy, validity, or clinical utility of contemporary damjeok. Nor is this distinction intended to diminish what patients report. It keeps the different observations as questions for future validation while preserving the safety boundary of appropriately investigating other causes that might explain the symptoms. These materials also do not support conclusions about treatment choice or effects.