Overview
GastroAGI
OverviewIntroduction Healthcare systems are increasingly recognizing the environmental impact of hospital food services, particularly the high carbon footprint associated with meat-heavy diets. At the same time, maintaining adequate nutritional quality for hospitalized patients remains essential, especially in acute care settings where malnutrition and increased metabolic demands are common.
Problem Statement Concerns persist that reducing meat-based meals in hospital settings could compromise protein intake and overall nutritional adequacy. Evidence evaluating whether plant-based or meat-free hospital menus can maintain comparable nutritional standards remains limited.
Summary This comparative nutrient analysis evaluated whether meat-free and plant-based alternatives could replace traditional meat-based hospital meals without compromising nutritional quality. The original inpatient menu consisted predominantly of meat-containing meals, with a substantial proportion derived from ruminant meats such as beef and lamb, which are associated with high environmental burden. The redesigned menu significantly reduced ruminant meat offerings and incorporated plant-based protein sources including legumes, dairy and eggs. Importantly, the alternative menu maintained comparable caloric, protein and fat content relative to the original menu, demonstrating that nutritionally balanced hospital meals can be achieved with substantially lower meat dependence. In addition, the plant-forward menu provided higher fibre content and modestly lower salt levels, potentially offering additional cardiometabolic benefits. The findings challenge the perception that meat reduction in hospital nutrition necessarily compromises protein adequacy or meal quality. Beyond nutrition, the study emphasizes the broader sustainability responsibilities of healthcare systems such as the NHS, which serve millions of meals annually and exert major influence on food procurement practices. The authors propose that environmentally conscious menu redesign can be implemented using currently available catering infrastructure without sacrificing patient nutritional standards. Although clinical outcomes and patient acceptability were not assessed, the study provides important proof-of-concept evidence supporting sustainable hospital nutrition strategies that align environmental stewardship with nutritional adequacy in modern healthcare systems.
Introduction Chronic idiopathic constipation (CIC) is one of the most common disorders of gut–brain interaction and is associated with substantial impairment in quality of life, healthcare utilization and economic burden. Although multiple effective prescription therapies are now available, real-world management of CIC continues to rely heavily on lifestyle modification and over-the-counter treatments.
Problem Statement Despite evolving treatment options and updated clinical guidelines, limited real-world data exist regarding treatment decision-making, barriers to therapy access, patient perceptions and financial burden in CIC care. Understanding the disconnect between healthcare provider practices and patient experiences is essential for improving long-term disease management and treatment accessibility.
Summary This large US real-world survey highlights important gaps between physician treatment strategies and patient experiences in chronic idiopathic constipation management. Most healthcare professionals reported following guideline-based escalation from lifestyle and dietary modification to over-the-counter agents and eventually prescription medications. However, a substantial proportion of patients who had never received prescription therapy were still considered clinically eligible for such treatment, suggesting underutilization of advanced therapies. Physicians prioritized long-term efficacy and improvement in quality of life when selecting treatment strategies, whereas patients emphasized symptom relief, affordability and treatment safety. Notably, patients frequently identified difficulty obtaining specialist appointments, limited awareness of available prescription medications and inadequate insurance coverage as major barriers to care. In contrast, physicians viewed medication cost and insurance authorization complexity as the primary prescribing obstacles. The study also demonstrated persistent reliance on lifestyle interventions despite relatively modest patient-perceived efficacy. Among prescription agents, linaclotide was generally viewed most favorably by clinicians, although overall patient satisfaction with available prescription therapies was high. Importantly, direct healthcare costs—including physician visits and medication co-payments—remained a meaningful financial burden. Overall, the study underscores that access limitations, insurance barriers and inadequate patient awareness continue to significantly influence CIC management despite the availability of effective pharmacologic therapies.
Introduction Serrated polyposis syndrome (SPS) is now recognized as the most common colorectal polyposis syndrome and an important precursor condition for colorectal cancer (CRC). The syndrome is characterized by multiple serrated colorectal lesions, including sessile serrated lesions and traditional serrated adenomas, which contribute substantially to colorectal carcinogenesis through the serrated neoplasia pathway.
Problem Statement Despite its clinical importance, SPS remains significantly underdiagnosed because serrated lesions are frequently subtle, flat and historically misclassified during colonoscopy. In addition, uncertainty persists regarding optimal endoscopic resection techniques and long-term surveillance strategies, with most current recommendations still based on expert opinion rather than high-quality prospective evidence.
Summary This review provides a contemporary overview of the evolving understanding and management of serrated polyposis syndrome, emphasizing the central role of improved endoscopic detection in reducing colorectal cancer risk. Advances in high-definition colonoscopy, chromoendoscopy, prolonged withdrawal times and refined lesion classification systems have substantially improved recognition of serrated lesions, particularly sessile serrated lesions that often present with indistinct borders and mucus caps. The review reinforces cold snare polypectomy as the preferred technique for most small nondysplastic serrated lesions because of its favorable safety profile and effective complete resection rates. For larger or dysplastic lesions, endoscopic mucosal resection remains the preferred strategy, although comparative evidence regarding cold, hot and underwater techniques specifically for serrated lesions remains limited. The article also highlights the growing shift toward individualized surveillance strategies in SPS. Although annual colonoscopy following colon clearance remains guideline standard, emerging evidence suggests that selected low-risk patients may safely undergo biennial surveillance, potentially reducing procedural burden without compromising cancer prevention. Overall, the review underscores that serrated neoplasia represents a major but still incompletely understood pathway in colorectal carcinogenesis and calls for further research to optimize detection, resection and surveillance strategies aimed at reducing interval and preventable colorectal cancers.
Introduction Modern biologic therapies have significantly improved remission rates in Crohn’s disease (CD), primarily through suppression of mucosal immune activation. However, despite clinical and endoscopic remission, many patients continue to experience recurrent disease flares, suggesting that deeper pathogenic mechanisms may persist even under effective immune-targeted treatment.
Problem Statement Current treatment paradigms in CD focus heavily on immune suppression, yet little is known about the residual dietary, microbial, metabolic and epithelial abnormalities that remain during remission. Understanding these persistent nonimmune perturbations may explain the relapsing nature of CD and identify adjunct therapeutic targets beyond biologic therapy alone.
Summary This comprehensive multiomics study demonstrates that substantial abnormalities in diet, gut microbiota, metabolome and ileal epithelial biology persist in Crohn’s disease despite effective clinical remission and advanced biologic therapy. Patients in remission showed marked suppression of adaptive T-cell and innate granulocyte pathways, reflecting strong immune inhibition, yet simultaneously exhibited persistent activation of epithelial antibacterial pathways including DUOX2, CEACAM6 and REG family genes. Increased goblet-cell and mucin glycosylation signatures were also observed, potentially representing a compensatory epithelial response to ongoing microbial disruption. Importantly, remission was still characterized by persistent dysbiosis, reduced microbial diversity and metabolomic abnormalities similar to those observed in active disease. Dietary analysis revealed sustained unhealthy dietary patterns during remission, particularly higher intake of ultra processed foods and lower consumption of fiber, vegetables and micronutrients. Exposure to ultra processed foods correlated strongly with microbial dysbiosis and negatively correlated with genes involved in mucin glycosylation and epithelial barrier maintenance, whereas Mediterranean dietary adherence showed favorable associations. Notably, higher epithelial antibacterial and mucus-related signatures, greater dysbiosis and increased ultra processed food exposure were associated with subsequent clinical flare risk. Overall, the study supports a major conceptual shift in CD management by demonstrating that immune suppression alone may not fully normalize gut biology and that adjunctive strategies targeting the diet–epithelium–microbiome axis could be essential for achieving deeper and more durable remission states.
Introduction Seronegative enteropathies (SNEs) represent a challenging group of disorders characterised by villous atrophy with negative coeliac serology. They include both seronegative coeliac disease (SNCD) and a broad spectrum of non-coeliac enteropathies such as infections, immune disorders, and drug-related causes. Their rarity, overlapping features, and lack of specific biomarkers make diagnosis difficult in routine practice. Problem Statement The biggest clinical issue is misdiagnosis. Many patients with non-coeliac enteropathies are incorrectly labelled as seronegative coeliac disease and started on a gluten-free diet. This leads to unnecessary lifelong dietary restriction, delayed diagnosis of the true underlying condition, and risk of poor outcomes. Differentiating SNCD from other causes of villous atrophy remains complex due to overlapping clinical and histological findings. Summary This review provides a practical framework for evaluating and managing SNEs. The key principle is systematic exclusion of non-coeliac causes before diagnosing SNCD. A definitive diagnosis of SNCD requires clinical and histological response to a gluten-free diet after other etiologies are ruled out. Non-coeliac enteropathies must be actively considered, including infections, immune-mediated diseases, medications, and malignancies. Accurate diagnosis is essential, as these conditions often require entirely different treatments. Long-term outcomes vary significantly. While appropriately treated SNCD has a favorable prognosis, misdiagnosed or untreated non-coeliac enteropathies may lead to serious complications and increased mortality. Overall, this review emphasizes a structured diagnostic approach, cautious use of gluten-free diet, and tailored management strategy to improve patient outcomes and avoid diagnostic pitfalls.
The Rome V Anorectal Disorders chapter introduces several important revisions that substantially modernize the diagnostic and therapeutic approach to anorectal disorders within the disorders of gut–brain interaction (DGBI) framework. The chapter integrates symptom-based diagnosis with objective physiology, updates terminology, refines diagnostic thresholds, and more clearly defines the role of anorectal testing and neuromodulation in routine practice.
One of the most important Rome V conceptual changes is the removal of the term “functional” from anorectal disorders, consistent with the broader Rome V framework.
This change applies across the anorectal disorders chapter:
functional anorectal disorders → anorectal disorders functional defecation disorder → dyssynergic defecation functional anorectal pain → anorectal pain disorders
This is more than semantic. It reflects the modern recognition that these disorders have measurable pathophysiology involving:
sensorimotor dysfunction, pelvic floor discoordination, visceral sensory dysfunction, and gut–brain dysregulation. 2. Rome V Reclassifies Anorectal Disorders Into 4 Major Categories
Rome V organizes anorectal disorders into 4 major categories:
Fecal incontinence (FI) Anorectal pain disorders Dyssynergic defecation (DD) Anorectal sensory dysfunction disorders
This classification is more clinically coherent and better aligned with anorectal physiology and test-based phenotyping than prior Rome versions.
Rome V substantially revises the diagnostic framework for fecal incontinence (FI).
FI is now defined as:
two or more episodes of uncontrolled passage of fecal material, with ≥1 episode/month documented on a 4-week stool diary, for the last 3 months, with symptom onset ≥6 months before diagnosis.
This is an important refinement because prior definitions used the term “recurrent,” which was vague and poorly standardized. Rome V replaces this with a measurable frequency threshold to improve:
clinical consistency, epidemiologic precision, and trial enrollment standardization. 4. Stool Diary Documentation Is Now Built Into FI Diagnosis
One of the most practical updates is that Rome V explicitly incorporates a 4-week stool diary into the diagnostic criteria for FI.
This is clinically important because stool diaries:
reduce recall bias, improve symptom quantification, improve phenotyping, and align diagnosis with trial methodology.
Rome V moves FI toward a more objective symptom-documentation model.
Rome V emphasizes that FI is heterogeneous and multifactorial, rather than simply a sphincter disorder.
The chapter highlights multiple contributing mechanisms:
internal anal sphincter weakness, external anal sphincter dysfunction, puborectalis dysfunction, rectal hyposensitivity, rectal hypersensitivity, impaired rectal compliance, neuropathy, impaired rectosigmoid brake, and psychological comorbidity.
This is a major conceptual advance because it shifts FI from a purely structural disorder to a multidimensional neurogastroenterologic disorder.
Rome V gives stronger emphasis to physiology-guided evaluation in FI.
Key tests include:
anorectal manometry (ARM), anal ultrasound (AUS), MRI, defecography, and neurophysiology testing.
The evidence summary table on pages 4–5 (Table 2) is one of the most clinically useful additions because it grades diagnostic utility and clarifies which tests are useful versus overused.
Most important takeaways:
ARM = high clinical utility (A1) AUS = useful for structural sphincter injury PNTML = rarely useful clinically translumbosacral anorectal magnetic stimulation = emerging neurophysiology tool. 7. PNTML Is De-emphasized; Modern Neurophysiology Is Favored
Rome V de-emphasizes pudendal nerve terminal motor latency (PNTML) because of:
methodological limitations, low sensitivity, and interobserver variability.
This is a meaningful de-escalation.
Instead, Rome V highlights translumbosacral anorectal magnetic stimulation as a more promising neurophysiologic tool for detecting lumbosacral neuropathy in:
fecal incontinence, levator ani syndrome, spinal cord injury, and mixed anorectal dysfunction. 8. Biofeedback Is Strongly Reinforced as First-Line Therapy in FI
Rome V gives stronger and more explicit support to biofeedback therapy (BT) for fecal incontinence.
This is one of the most important practical messages in the chapter.
Biofeedback is recommended because it:
improves anal squeeze strength, improves squeeze duration, improves rectal sensory discrimination, corrects dyssynergia when present, and improves quality of life.
The RCT summary on pages 8–14 (Table 3) is highly practice-relevant and shows consistent efficacy of biofeedback across multiple controlled trials.
A highly practical Rome V update is formal recognition that home biofeedback is non-inferior to office biofeedback in selected patients.
This is a major translational advance because it improves:
accessibility, scalability, adherence, and real-world delivery of pelvic floor rehabilitation.
This is one of the most clinically implementable Rome V updates.
Rome V substantially expands the role of neuromodulation in FI management.
Major updates:
Sacral nerve stimulation (SNS) remains an important option in refractory FI Percutaneous tibial nerve stimulation has weak evidence Translumbosacral neuromodulation therapy (TNT) emerges as a promising newer therapy with sham-controlled supportive data.
The therapeutic schematic on page 7 (Figure 1) is especially useful because it visually summarizes current and emerging neuromodulation strategies.
Rome V improves the diagnostic clarity of levator ani syndrome (LAS).
LAS is now defined by:
chronic/recurrent anorectal pain, episodes lasting ≥30 minutes, puborectalis tenderness, and exclusion of structural causes.
Rome V removes older restrictive descriptors (such as posterior traction emphasis) and broadens tenderness assessment to reflect more accurate examination findings.
Mechanistically, LAS is reframed as involving:
pelvic floor hypertonicity, dyssynergia, and lumbosacral neuropathy, rather than being considered merely idiopathic pain. 12. Biofeedback Is Now the Preferred Therapy for Levator Ani Syndrome
One of the most clinically important updates in anorectal pain is that biofeedback is now the preferred evidence-based therapy for levator ani syndrome, especially when levator tenderness is present.
This is one of the clearest Rome V therapeutic upgrades.
In the cited RCT:
87% improved with biofeedback, versus 45% with electrical stimulation, and 22% with massage.
This makes biofeedback the strongest supported intervention for LAS.
Rome V retains proctalgia fugax with clearer criteria:
sudden severe anorectal pain, lasting seconds to minutes, complete resolution between episodes, unrelated to defecation.
Management remains conservative:
reassurance is first-line, inhaled salbutamol may help severe prolonged attacks, but evidence remains limited. 14. Dyssynergic Defecation Is One of the Most Important Rome V Revisions
The Rome V revision of dyssynergic defecation (DD) is one of the most clinically important updates in the chapter.
Rome V makes several major changes:
removes “functional” broadens symptom entry criteria removes EMG from core diagnostic requirements simplifies physiologic confirmation eliminates older subtype complexity.
This is a major simplification with direct clinical relevance.
This is one of the most practice-changing updates.
Rome V now allows diagnosis of DD when:
the patient has symptoms of difficult evacuation, and one abnormal physiologic test is present.
Previously, Rome IV required ≥2 abnormal tests.
Rome V now classifies:
probable DD = 1 abnormal test definite DD = ≥2 abnormal tests.
This is a major practical simplification that reduces diagnostic friction and unnecessary testing.
Rome V clarifies that the most useful core tests for DD are:
anorectal manometry (ARM) balloon expulsion test (BET)
These are now the central diagnostic tests for routine evaluation.
Defecography is repositioned as:
supportive, adjunctive, and mainly useful when ARM/BET are inconclusive.
This is one of the most practical diagnostic updates in the chapter.
Rome V strongly reinforces that biofeedback is the most effective treatment for DD.
This remains one of the strongest evidence-based interventions in all DGBI.
Across multiple RCTs, biofeedback consistently outperformed:
laxatives, diazepam, sham therapy, counseling, and standard care.
This remains one of the strongest therapeutic recommendations in Rome V.
Rome V now gives clearer diagnostic identity to anorectal sensory dysfunction disorders:
rectal hyposensitivity rectal hypersensitivity
This is an important conceptual advance because these disorders are now formally recognized as distinct sensorimotor phenotypes rather than secondary physiologic observations.
Clinical Bottom Line
The Rome V Anorectal Disorders chapter modernizes anorectal DGBI by integrating symptom-based diagnosis with objective physiology, simplified testing pathways, and mechanism-based therapy.
The most practice-changing updates are:
“functional” terminology removed anorectal disorders reorganized into 4 physiologic categories FI criteria now standardized with stool diary incorporation FI recognized as a heterogeneous sensorimotor disorder PNTML is de-emphasized biofeedback is strengthened as first-line therapy in FI, LAS, and DD home biofeedback is validated TNT emerges as a promising neuromodulation strategy DD diagnosis is simplified (1 abnormal test = probable DD) ARM + BET are now the core tests for DD anorectal sensory disorders are formally recognized as distinct diagnostic entities.
The Rome V Bowel Disorders chapter is one of the most clinically relevant revisions in Rome V because it substantially updates the diagnostic framework for disorders of gut–brain interaction (DGBI) involving bowel symptoms. The major conceptual advance is a shift away from exclusion-based diagnosis and rigid “functional” terminology toward positive symptom-based diagnosis, biologically plausible phenotyping, and pragmatic treatment pathways. Rome V also reframes bowel disorders as a spectrum of overlapping DGBI, rather than isolated, mutually exclusive syndromes.
A major Rome V conceptual change is the abandonment of the term functional bowel disorders in favor of bowel disorders (BDs). This aligns with the broader Rome V movement away from the term “functional,” which has long been criticized as mechanistically vague, scientifically outdated, and often stigmatizing for patients.
This change reflects a modern DGBI framework:
symptoms are biologically real, mechanisms are multifactorial, and absence of structural disease does not imply absence of pathophysiology. 2. Rome V Reclassifies Bowel Disorders Into 6 Distinct Categories
Rome V now classifies bowel disorders into 6 categories:
Irritable bowel syndrome (IBS) Chronic constipation (CC) Functional diarrhea (FDr) Functional abdominal bloating (FAB) Unclassified bowel disorder (U-BD) Opioid-induced constipation (OIC)
This classification is important because it better reflects clinical overlap and real-world symptom clusters. The spectrum diagram on page 2 (Figure 1) is particularly useful because it visually demonstrates how constipation, diarrhea, pain/discomfort, bloating, and distension overlap across syndromes rather than existing as isolated entities.
This is one of the most important Rome V changes.
Rome V reintroduces “abdominal discomfort” into the diagnostic criteria for IBS, reversing one of the most debated Rome IV decisions.
Under Rome IV, IBS required abdominal pain at least 1 day/week. Rome V now defines IBS by:
recurrent, but not continuous, abdominal pain and/or discomfort at least 3 days/month for the last 3 months, with symptom onset ≥6 months before diagnosis, associated with ≥2 stool-related features.
This is a major and clinically sensible revision because:
many true IBS patients report discomfort rather than pain, symptom language varies across cultures, and Rome IV likely underdiagnosed IBS by being too restrictive. 4. Rome V Lowers the IBS Symptom Frequency Threshold
Rome V lowers the IBS frequency threshold from ≥1 day/week (Rome IV) to ≥3 days/month.
This is a highly practical and evidence-based change.
The Rome Foundation Global Epidemiology Study showed that Rome IV significantly reduced IBS prevalence largely because the pain threshold was too stringent. Rome V corrects this by lowering the threshold and restoring diagnostic sensitivity without abandoning specificity.
Rome V now explicitly states that IBS symptoms should be recurrent, not continuous.
This is an important refinement because it helps distinguish IBS from centrally mediated abdominal pain syndrome, where pain is more continuous and less clearly linked to bowel function.
This is a subtle but clinically useful diagnostic discriminator.
Rome V strongly reinforces one of the most important modern DGBI principles:
IBS should be diagnosed positively based on symptoms, not by exclusion.
This is a major practice message.
When Rome V criteria are met and alarm features are absent:
diagnostic confidence should be high, testing should be selective, and clinicians should avoid reflex over-investigation.
Rome V strongly discourages exhaustive exclusionary workups in routine IBS.
Rome V recommends limited, targeted testing in suspected IBS rather than broad exclusionary panels.
Most clinically relevant recommendations:
Fecal calprotectin is useful to exclude IBD (high negative predictive value) Celiac serology should be considered, especially in IBS-D stool infection testing only when epidemiologically indicated colonoscopy only when alarm features exist or microscopic colitis is suspected routine stool microbiome/SIBO testing is not recommended.
The stepwise diagnostic algorithm on page 7 (Figure 4) is one of the most clinically useful figures in the chapter because it operationalizes efficient diagnostic triage.
This is one of the most important practical updates.
Rome V explicitly states that routine breath testing for SIBO (or intestinal methanogen overgrowth) is not recommended in the initial diagnostic evaluation of IBS.
The rationale is strong:
poor test standardization, limited diagnostic accuracy, inconsistent clinical utility, insufficient evidence that testing improves outcomes.
This is an important de-escalation in an overused area of practice.
Rome V does not recommend routine initial testing for bile acid malabsorption (BAM) in IBS-D, but advises considering it in:
chronic diarrhea, refractory IBS-D, post-cholecystectomy patients, or when standard therapy fails.
This is a practical and evidence-aligned change that appropriately narrows BAM testing.
Rome V replaces functional constipation (FC) with chronic constipation (CC).
This is both a linguistic and conceptual update:
more clinically intuitive, less stigmatizing, and more consistent with contemporary DGBI terminology.
Rome V also explicitly notes that:
CC, FC, and CIC are largely interchangeable in practice, but CC is now preferred nomenclature. 11. The Main Distinction Between IBS-C and CC Is Predominant Pain
Rome V clarifies that the key clinical distinction between IBS-C and CC is not constipation severity—it is whether abdominal pain/discomfort is the predominant symptom.
This is one of the most clinically useful practical clarifications in the chapter.
IBS-C = constipation + predominant abdominal pain/discomfort CC = constipation with minimal/non-predominant pain 12. Rome V Delays Anorectal and Transit Testing in Chronic Constipation
Rome V recommends that anorectal physiology and transit testing should not be part of the initial routine evaluation in most patients with chronic constipation.
Instead:
begin with symptom-based diagnosis, initiate empiric therapy, reserve anorectal testing for refractory symptoms or suspected defecatory disorder.
This is a major practical simplification.
Rome V retains functional diarrhea (FDr) and clarifies that it differs from IBS-D because abdominal pain is not the predominant symptom.
This distinction mirrors the IBS-C vs CC separation and improves internal diagnostic consistency across bowel disorders.
Rome V formally recognizes functional abdominal bloating (FAB) as a distinct bowel disorder rather than merely a secondary symptom construct.
This is an important upgrade because bloating/distension is:
highly prevalent, often the dominant symptom, and frequently underrecognized in routine practice.
Rome V also formally distinguishes:
bloating = subjective sensation distension = objective measurable increase in girth 15. Abdominophrenic Dyssynergia Is Highlighted as a Key Mechanism of Bloating
One of the most important mechanistic additions in Rome V is the recognition of abdominophrenic dyssynergia as a major pathophysiologic driver of visible abdominal distension.
This is a highly important mechanistic update.
Rome V emphasizes that many patients with bloating do not have excess intestinal gas. Instead, visible distension may result from:
paradoxical diaphragmatic contraction, abdominal wall relaxation, and altered viscerosomatic reflexes.
This is one of the most important physiologic advances in the chapter.
The treatment pyramid on page 7 (Figure 5) is one of the most practical additions in Rome V. It formalizes a stepwise approach to bowel disorders:
diagnosis and explanation reassurance and symptom framing dietary intervention symptom-targeted pharmacotherapy brain–gut behavioral therapies multidisciplinary care
This figure is one of the most clinically useful Rome V additions because it operationalizes modern DGBI care.
Rome V gives stronger support than prior iterations to:
CBT, gut-directed hypnotherapy, mindfulness, digital behavioral therapies.
This is a major management evolution and reinforces DGBI as a gut–brain disorder rather than a purely bowel-localized condition.
Clinical Bottom Line
The Rome V Bowel Disorders chapter modernizes bowel DGBI by replacing rigid exclusionary frameworks with positive diagnosis, selective testing, symptom phenotyping, and multidisciplinary care.
The most practice-changing updates are:
“functional bowel disorders” renamed bowel disorders IBS now includes pain and/or discomfort IBS threshold lowered to ≥3 days/month IBS must be recurrent, not continuous IBS is a positive diagnosis, not exclusionary routine SIBO testing is discouraged CC replaces functional constipation IBS-C vs CC distinction is based on predominant pain FAB is now a formal standalone disorder abdominophrenic dyssynergia is recognized as a key bloating mechanism care is formalized through a stepwise multidisciplinary treatment pyramid.
The Rome V process represents the most rigorous methodological evolution in the history of the Rome Foundation and marks a major conceptual maturation in how disorders of gut–brain interaction (DGBI) are defined, classified, and managed. Compared with Rome IV, Rome V is not simply a criteria revision; it is a full conceptual modernization of DGBI, integrating updated pathophysiology, evidence-based diagnostic refinement, stigma-sensitive terminology, and a stronger biopsychosocial therapeutic framework.
The most fundamental conceptual advance in Rome V is the continued and complete transition away from the older term “functional gastrointestinal disorders (FGID)” toward “disorders of gut–brain interaction (DGBI)”, with Rome V explicitly recommending that FGID should no longer be used.
This is one of the most important changes in the Rome V process because it directly addresses the long-standing stigma associated with the term “functional,” which historically implied:
non-organic disease, psychosomatic illness, psychiatric illness, or illegitimate symptoms.
Rome V fully adopts DGBI as the preferred term because it is:
more biologically accurate, more mechanistically grounded, less stigmatizing, and more acceptable to patients, clinicians, regulators, and industry.
This change is not semantic—it is foundational. Rome V explicitly frames DGBI as disorders arising from measurable disturbances in:
motility, visceral sensitivity, mucosal/immune function, gut microbiota, and central nervous system processing.
This is the core scientific identity of Rome V.
Rome V was developed over 7 years (2019–2026) by 144 international experts from 27 countries across 25 committees, making it the largest and most rigorous Rome effort to date.
A major methodological advance is that Rome V moved even further away from consensus-only expert opinion and toward prospective and retrospective evidence synthesis, using consensus only when evidence was insufficient.
Compared with prior Rome iterations:
earlier Rome versions were largely consensus-based, Rome IV introduced stronger evidence requirements, Rome V applies the most stringent evidence threshold yet.
This is one of the most important process-level changes in Rome V and strengthens the scientific legitimacy of the criteria.
One of the most practice-changing methodological innovations in Rome V is the explicit distinction between:
Rome V research criteria, and Rome Foundation clinical criteria.
This is a major advance because Rome acknowledges that strict research thresholds are often too rigid for real-world clinical practice.
Rome V recognizes three major limitations of standard Rome research criteria:
A. Subdiagnostic Symptom Burden Is Clinically Real
Rome V highlights that a large proportion of patients have clinically meaningful GI symptoms but do not meet full Rome criteria.
A major global study cited in Rome V showed:
41.4% met formal Rome criteria, 33.4% had no GI symptoms, but nearly 25% had clinically important “subdiagnostic” GI symptoms.
These patients still had:
impaired quality of life, higher anxiety/depression, greater healthcare use, and significant work/life burden.
Rome V therefore explicitly recognizes that these patients still warrant diagnosis and treatment.
B. Symptom Overlap Is the Rule, Not the Exception
Rome V formally recognizes that multiple overlapping DGBI are common and clinically important, rather than confounding noise.
This is a major clinical advance because patients frequently present with overlapping:
esophageal, gastroduodenal, bowel, and centrally mediated pain disorders.
Rome V emphasizes that overlapping DGBI are associated with:
worse symptom severity, greater psychosocial burden, poorer quality of life, more medical utilization.
This is highly clinically relevant and improves real-world applicability.
C. “Bothersomeness” Is Elevated as a Clinical Standard
Rome V introduces bothersomeness as a formal clinical principle.
This is one of the most clinically important practical changes in the entire document.
Rather than relying rigidly on research-style duration/frequency thresholds, Rome V states that in clinical care, diagnosis is justified when:
symptom quality matches the Rome phenotype, organic disease is sufficiently excluded, and symptoms are sufficiently bothersome to impair life or prompt care-seeking.
This is a major real-world improvement and makes Rome V far more clinically usable.
Rome V strongly reinforces one of the Rome Foundation’s most important philosophical contributions: DGBI should be diagnosed positively, not merely by exclusion.
This remains a central Rome principle, but Rome V strengthens it further through:
updated symptom-based criteria, stepwise diagnostic algorithms, selective testing, and physiology-supported phenotyping.
The major practical implication is clear: clinicians should not pursue endless exclusionary testing once a positive DGBI diagnosis is established and alarm features are absent.
Rome V formalizes diagnostic algorithms for all DGBI categories and integrates them into the 3rd edition of Rome V Diagnostic Algorithms for Common GI Symptoms.
This is a major methodological advance because Rome criteria alone define syndromes, but algorithms now provide:
structured evaluation pathways, symptom-to-test sequencing, rational exclusion of mimics, and more reproducible clinical decision-making.
This is one of the most clinically actionable changes in Rome V.
Rome V explicitly acknowledges that diagnosis alone is insufficient for management and strengthens the Multidimensional Clinical Profile (MCP) as a central clinical framework.
This is a major practical and conceptual advance because Rome V emphasizes that treatment must be individualized using:
symptom phenotype, physiologic mechanisms, psychosocial comorbidity, illness severity, quality-of-life burden, and healthcare impact.
This is one of the clearest statements in Rome V that DGBI care must move beyond diagnosis into structured personalized phenotyping.
The biopsychosocial conceptual model remains the intellectual core of Rome V and is more robustly developed than in Rome IV. The diagram on page 8 explicitly maps the interaction among early life factors, psychosocial factors, physiology, DGBI presentation, and outcomes, emphasizing bidirectional brain–gut signaling rather than linear causality.
This remains one of the most important conceptual strengths of Rome V.
Rome V strengthens mechanistic integration of:
early life influences, psychosocial stress, visceral hypersensitivity, immune activation, microbiome, food/diet, autonomic dysfunction, and central pain modulation.
The key message is that DGBI are not “psychological disorders” and not merely “motility disorders”; they are multisystem disorders of integrated gut–brain dysregulation.
One of the most clinically important but often underappreciated Rome V advances is the explicit positioning of the therapeutic relationship as treatment.
Rome V devotes a full section to the 12 steps to enhance the therapeutic relationship, emphasizing that clinician behavior directly affects:
symptom severity, healthcare utilization, treatment adherence, quality of life, and outcomes.
This is a major practical advance and one of the strongest reaffirmations in Rome V that communication is not ancillary—it is therapeutic.
Rome V more explicitly links treatment intensity to illness severity and formalizes a mild–moderate–severe framework for DGBI management.
This is clinically important because it aligns treatment with disease burden:
Mild: education, reassurance, diet/lifestyle Moderate: symptom monitoring, targeted pharmacotherapy, brain–gut behavioral therapy Severe: neuromodulators, structured psychosocial care, multidisciplinary DGBI referral
This is one of the most clinically practical therapeutic frameworks in Rome V.
Clinical Bottom Line
The Rome V process is not merely a criteria update—it is a full modernization of DGBI science and clinical care. Its most important advances are:
full replacement of FGID with DGBI, strongest evidence-based Rome methodology to date, separation of research vs clinical criteria, recognition of subdiagnostic and overlapping DGBI, formal use of bothersomeness in clinical diagnosis, expanded diagnostic algorithms, stronger multidimensional clinical profiling, deeper biopsychosocial integration, and formal recognition that the therapeutic relationship itself is part of treatment.
The single most important Rome V process advance is this: DGBI are now framed not as diagnoses of exclusion, but as positive, biology-informed, clinically actionable disorders requiring structured biopsychosocial care.
Rome V reframes pediatric lower gastrointestinal disorders of gut–brain interaction (DGBI) around symptom clusters and anatomic domains rather than age-based groupings, a clinically important shift that better reflects how these disorders present in practice across childhood and adolescence. The lower DGBI spectrum is now organized into abdominal pain disorders, defecation and anorectal disorders, and discomfort disorders, allowing clinicians to approach symptoms according to dominant physiology rather than rigid age cutoffs. This revision also formally recognizes several entities that pediatric gastroenterologists have long encountered but previously lacked standardized pediatric definitions for, including biliary pain syndrome, centrally mediated abdominal pain syndrome, proctalgia fugax, and functional abdominal bloating. The practical consequence is earlier recognition, reduced diagnostic ambiguity, and less exposure to inappropriate testing or empiric treatment in children with otherwise poorly classified symptoms.
Irritable Bowel Syndrome: Pain Becomes the Diagnostic Anchor
Rome V sharpens the pediatric definition of irritable bowel syndrome (IBS) by making abdominal pain, rather than bowel habit disturbance alone, the dominant diagnostic feature. This is a clinically meaningful departure from Rome IV, particularly in children with constipation. Rather than requiring a trial of constipation treatment to separate IBS-C from functional constipation, Rome V now distinguishes the two by symptom dominance: when abdominal pain is the primary complaint and is linked to stooling, IBS is favored; when bowel dysfunction predominates and pain is secondary, functional constipation is more appropriate. This change better reflects real-world pediatric presentations and avoids prolonged diagnostic uncertainty. The criteria also now exclude pain occurring solely during menses, reducing misclassification of dysmenorrhea as IBS in adolescent girls.
Mechanistically, pediatric IBS is increasingly understood as a disorder of altered gut–brain signaling rather than a purely motility-based condition. Rome V reinforces the relevance of early-life programming, including antibiotic exposure, neonatal interventions, early infection, and adverse psychosocial experiences, all of which may prime visceral hypersensitivity and dysregulated central pain processing. Children with IBS show lower rectal sensory thresholds, increased intestinal permeability, low-grade mucosal immune activation, altered microbial composition, and food-triggered symptom amplification. These mechanistic insights are clinically relevant because they support individualized therapy rather than symptom suppression alone. In practice, evaluation should be directed by phenotype. IBS-D warrants screening for celiac disease, inflammatory markers, and selective evaluation for bile acid malabsorption or carbohydrate malabsorption. IBS-C requires differentiation from primary defecatory disorders. The strongest therapeutic evidence remains for gut–brain therapies, particularly cognitive behavioral therapy and hypnotherapy, both of which should be considered first-line in children with clinically significant IBS. Adjunctive therapies such as percutaneous electrical nerve field stimulation, selected probiotics, enteric-coated peppermint oil, psyllium, and subtype-specific bowel therapies can be layered according to phenotype and severity.
Abdominal Pain Syndrome–Not Otherwise Specified: The Intermittent Pain Phenotype
Rome V replaces functional abdominal pain–not otherwise specified with abdominal pain syndrome–not otherwise specified (APS-NOS), clarifying this as an intermittent pain disorder that does not meet criteria for IBS, functional dyspepsia, abdominal migraine, or biliary pain syndrome. The distinction is clinically useful because it captures children with recurrent abdominal pain who often undergo extensive evaluation but do not fit a better-defined Rome phenotype. Rome V also explicitly distinguishes APS-NOS from centrally mediated abdominal pain syndrome by emphasizing intermittent rather than continuous pain. Pain occurring exclusively with meals, bowel movements, or menses should prompt alternative diagnoses.
From a mechanistic standpoint, APS-NOS likely shares many pathophysiologic pathways with IBS, including altered visceral perception, dysregulated autonomic signaling, and psychosocial amplification, but without a defining stool pattern or meal association. In practice, evaluation is guided by exclusion of inflammatory, structural, and celiac pathology when clinically indicated, followed by reassurance and early symptom-directed management. The therapeutic approach parallels IBS, with strongest evidence for CBT, hypnotherapy, and neuromodulation strategies rather than escalating diagnostic testing.
Biliary Pain Syndrome: A New Pediatric Rome Diagnosis With Major Clinical Implications
Biliary pain syndrome is one of the most important additions in Rome V because it introduces a formal pediatric diagnostic framework for children previously labeled with “biliary dyskinesia,” a term widely used but poorly standardized. Rome V intentionally moves away from the surgical shorthand of biliary dyskinesia and instead defines a symptom-based DGBI characterized by episodic right upper quadrant pain, often postprandial, severe enough to prompt acute evaluation, in the absence of gallstones or structural biliary disease. This is highly relevant in pediatric practice, where increasing rates of cholecystectomy have often been driven by nonspecific symptoms and unreliable gallbladder ejection fraction studies.
The Rome V position is clinically decisive: gallbladder ejection fraction should not be used diagnostically in isolation, and cholecystectomy should not be reflexive. Evaluation should prioritize exclusion of stones, biliary tract pathology, pancreatobiliary structural disease, and biochemical abnormalities through ultrasound, selective MRCP, and liver-pancreatic biochemistry. In many children, conservative management may outperform surgery over time, and spontaneous improvement is well documented. Rome V therefore shifts pediatric practice toward diagnostic restraint and away from surgery-first decision making. This is likely to reduce unnecessary cholecystectomy in adolescents with functional pain syndromes.
Abdominal Migraine: Episodic Neuroenteric Pain, Not Functional Dyspepsia
Rome V retains abdominal migraine unchanged, reflecting continued confidence in its construct as a stereotyped episodic pain syndrome within the migraine spectrum. This remains an important diagnosis in children with severe recurrent periumbilical or diffuse pain accompanied by pallor, nausea, vomiting, headache, or photophobia. The practical importance lies in recognizing abdominal migraine as a neuroenteric episodic disorder rather than misclassifying it as refractory dyspepsia or recurrent unexplained abdominal pain.
The mechanistic model is increasingly aligned with cyclic vomiting syndrome and migraine biology, involving neuronal hyperexcitability, altered gastric motor function, and possibly mitochondrial dysfunction. Clinically, this diagnosis matters because it reframes treatment away from repeated gastrointestinal investigation and toward trigger identification, migraine-style prophylaxis, and selected abortive therapy. In children with frequent disabling attacks, cyproheptadine, propranolol, pizotifen, and flunarizine remain practical preventive options, while severe attacks may respond to triptan-based or antiemetic rescue strategies.
Centrally Mediated Abdominal Pain Syndrome: Recognizing the Continuous Pain Phenotype
Centrally mediated abdominal pain syndrome (CAPS) is another major addition in Rome V and fills a longstanding gap in pediatric DGBI classification. CAPS identifies children with continuous abdominal pain and functional impairment in whom central pain amplification, rather than peripheral gastrointestinal dysfunction, is likely the dominant driver. This diagnosis is clinically important because it validates a phenotype that is often over-investigated, mislabeled, or treated as refractory IBS despite a distinct pain biology.
The practical implication is that continuous pain should prompt a different clinical strategy than intermittent pain syndromes. CAPS requires a multidisciplinary model centered on functional restoration, pain neuroscience education, school reintegration, and targeted brain–gut therapies. Psychological assessment is essential, not to psychologize symptoms, but to identify pain-specific cognitions, maladaptive coping, family responses, and disability drivers. Neuromodulators, including tricyclics, SSRIs, mirtazapine, gabapentinoids, and behavioral therapies, are mechanistically aligned with CAPS and should be prioritized over repeated diagnostic escalation.
Functional Constipation: Clarified Criteria, Stronger Clinical Precision
Rome V preserves functional constipation as a distinct entity but improves diagnostic precision by clarifying stool retention behaviors, stool form descriptors, and symptom frequency. Most importantly, Rome V explicitly separates constipation from IBS by emphasizing that when abdominal pain is the dominant symptom and improves with defecation, IBS should be favored. This distinction is highly relevant in pediatric practice, where constipation and pain frequently overlap and are often conflated.
Rome V continues to support a clinically grounded approach: diagnosis is usually made from history and examination, not imaging. Routine abdominal radiographs remain low-yield and should not be used reflexively. Treatment remains structured and pragmatic, beginning with education, disimpaction, maintenance laxative therapy, toileting behavior, and escalation to stimulant laxatives or newer agents such as linaclotide in selected refractory cases. The guideline also reinforces that refractory constipation is a separate management problem requiring escalation to motility-focused interventions rather than indefinite cycling of standard laxatives.
Functional Diarrhea and Functional Abdominal Bloating: Symptom-Led, Mechanism-Aware Diagnosis
Rome V broadens functional diarrhea across the pediatric age spectrum and provides a more clinically useful distinction from IBS-D by emphasizing that diarrhea without pain is functional diarrhea, whereas pain-predominant diarrhea is IBS-D. This distinction is especially useful in adolescents, where overlap is common and symptom labeling has therapeutic consequences. Evaluation should remain conservative but targeted, focusing on malabsorption, inflammation, and dietary contributors only when clinically justified.
Functional abdominal bloating is newly recognized and clinically valuable because it legitimizes a symptom complex commonly encountered in practice but often poorly classified. Rome V acknowledges that bloating and visible distension may reflect distinct mechanisms including gas handling abnormalities, carbohydrate fermentation, abdominophrenic dyssynergia, pelvic floor dysfunction, visceral hypersensitivity, and behavioral stool retention. This is particularly relevant in adolescents with distension out of proportion to stool burden or gas volume. Management should therefore move beyond empiric simethicone and include attention to fermentation load, posture, evacuation mechanics, and in selected cases, biofeedback-directed correction of abdominophrenic discoordination.
Infant Distress Syndrome: A More Accurate Framework Than “Infantile Colic”
Rome V replaces “infantile colic” with infant distress syndrome (IDS), a clinically and conceptually important change. The term “colic” implied pain of colonic origin without evidence; IDS instead frames excessive crying as a multifactorial disorder of gut–brain regulation in early infancy. This is more biologically plausible and clinically useful. Rome V also removes the rigid 3-hour crying threshold from routine clinical diagnosis, recognizing that caregiver burden, not just crying duration, determines clinical significance.
This change has practical value in pediatric care because it validates distressed infants who previously fell below arbitrary research cutoffs but still caused major caregiver dysfunction. Evaluation remains focused on exclusion of red flags and caregiver assessment rather than indiscriminate investigation. IDS is best managed through reassurance, caregiver support, normalization of symptom trajectory, and selective use of low-risk interventions such as Limos lactobacillus reuteri or cow’s milk elimination in selected infants. The shift from “colic” to IDS is not merely semantic; it reframes the condition from presumed intestinal pain to early-life dysregulation of gut–brain function and caregiver-infant interaction.
Introduction A significant number of patients with inflammatory bowel disease in remission continue to report symptoms such as abdominal pain, bloating, and altered bowel habits. These symptoms often mimic irritable bowel syndrome, creating confusion in clinical practice. Physicians frequently struggle to differentiate between ongoing subclinical inflammation and functional symptoms, leading to variability in management. This joint consensus from the Rome Foundation and the International Organisation for the Study of IBD provides a structured, evidence-based approach to defining, evaluating, and managing these patients. Why This Guideline Was Required The absence of standardised terminology and diagnostic criteria has led to a major clinical problem: patients with quiescent IBD are often misclassified as having active disease, resulting in unnecessary escalation of immunosuppressive or biologic therapies. At the same time, failure to recognise functional symptoms may delay appropriate therapies such as dietary interventions or brain–gut behavioral treatments. This consensus aims to bridge this gap by clearly separating inflammatory activity from functional symptom burden. Key Takeaways for Clinicians
We are pioneers in clinical intelligence, dedicated to helping gastroenterologists harness the power of artificial intelligence to drive precision, efficiency, and patient growth.