Rome V: minimizing "functional", maximizing precision in gut-brain disorders.

Abstract

Rome V represents a major conceptual and clinical evolution in the field of disorders of gut-brain interaction (DGBI). Its most important contribution is the deliberate move away from the term "functional", a label that has often implied that symptoms are less real, less biological, or merely psychological. By emphasizing DGBI, Rome V reframes these conditions as positive diagnoses arising from altered gut-brain regulation, visceral sensitivity, motility, mucosal and immune mechanisms, microbiota, autonomic function, and central processing. Beyond terminology, Rome V introduces greater diagnostic precision. In esophageal disorders, the exclusion of gastroesophageal reflux disease and major motor disorders is aligned with Lyon Consensus 2.0 and Chicago Classification v4.0, while globus and functional chest pain are refined to avoid unnecessary interventions. In gastroduodenal disorders, functional dyspepsia is better phenotyped according to meal-related symptoms, with clearer distinctions from chronic nausea and vomiting syndrome, gastroparesis, cyclic vomiting syndrome, cannabinoid hyperemesis syndrome, rumination, and inability to belch. In bowel disorders, Rome V reintroduces abdominal discomfort into IBS criteria, changes the symptom frequency threshold, renames functional constipation as chronic constipation, and redefines abdominal bloating/distension. The anorectal section is particularly relevant because it operationalizes fecal incontinence, defines dyssynergic defecation using objective testing, and formally recognizes rectal hypo- and hypersensitivity, which may guide biofeedback therapy. Rome V also raises future challenges: implementation in clinical practice, patient-centered communication, avoidance of reductionism, development of mechanism-based research, and interpretation of forthcoming epidemiological data. Overall, Rome V promotes precision, reduces stigma, and supports more rational, mechanism-based care.