DAY 2: Applying the New Rome V Criteria to Clinical Practice

Dr. Chang started her presentation with a high-level overview of the changes in Rome V, including a shift in care for disorders of gut-brain interaction (DGBI) away from diagnosis by exclusion and toward patient-centered and mechanism-informed diagnosis. The Rome Foundation revises its criteria about every 10 years, but the process starts with 3 years of preparatory work. This update involved 144 investigators from 27 countries, with the goals of updating the criteria for use in both real-world care and research across settings and cultures, alignment with current evidence, and inclusion of patients whom overly strict research thresholds had previously left out.

The term “functional gastrointestinal disorders” was replaced by the term “disorders of gut-brain interaction” and the concept of “symptom bothersomeness” was favored over rigid symptom-frequency cutoffs. Disorders are now grouped by anatomic region. Rome V also gives more weight to social determinants of health, trauma, stigma, and LGBTQ+ health factors. Two new diagnoses were added. The first is “inability to belch syndrome,” also called retrograde cricopharyngeal dysfunction, defined as a bothersome inability or impaired ability to belch at least 3 days per week, with no evidence of a major underlying esophageal disorder. The second is “abdominal migraine,” characterized by paroxysmal, incapacitating, intense episodes of abdominal pain that usually last from 1 hour to less than 1 day. Episodes occur at least 3 times per year, with at least 2 episodes in the previous 6 months. They are associated with a personal or family history of migraine, and episodes can involve photophobia, pallor, aura, anorexia, nausea, or vomiting.

The criteria also refine the distinction between irritable bowel syndrome (IBS) and centrally mediated abdominal pain syndrome (CAPS), which lie along a pathologic continuum. IBS pain is peripheral, not continuous, and occurs at least 3 days per month over the last 3 months, whereas CAPS involves continuous pain and usually develops in patients with other chronic pain disorders such as fibromyalgia.

Rome V goes beyond diagnostic criteria. It describes the gut lumen as a dynamic signaling center where diet and the microbiome interact with the host to produce symptoms, which points to new diet- and microbiome-based treatment targets. It makes clear that understanding DGBI requires attention to the patient’s experience, identity, and context, not only biology. It also holds that effective management should be personalized and patient-centered, integrating behavioral therapies and neuromodulators and recognizing the role of the patient–provider relationship.

In clinical practice, the workup should assess symptoms, how bothersome they are, how often they occur, and how long they have lasted, and refer to the various Rome V algorithms to guide evaluation and treatment. The criteria can be applied flexibly in practice, with strict thresholds reserved for research. Clinicians should avoid tests when the results will not change management. Dr. Chang also acknowledged that the term “DGBI” can be stigmatizing to patients, and advised against using it with patients or implying that something is wrong with the brain. Instead of opening with a diagnostic label, clinicians can review the symptoms, explain how they likely developed, and discuss treatments that match that pathophysiologic mechanism.

Overall, Rome V brings updated physiologic testing, refined symptom thresholds, new diagnoses, and more emphasis on gut-brain mechanisms, patient experience, and individualized care. The goal is to improve diagnostic confidence, reduce stigma, and support more targeted treatment for patients with DGBI. An overview of Rome V criteria development can be found at Drossman DA, et al. Gastroenterology. 2026;170:1224-1239. doi: 10.1053/j.gastro.2026.02.014