What is new in Rome V?: Redefining diagnostic criteria and clinical pathways in disorders of gut-brain interaction.

The Rome-V criteria represent a major evolution in the conceptualization and clinical application of disorders of gut-brain interaction (DGBIs). Building upon the biologically grounded framework established in Rome IV, Rome V moves beyond rigid symptom-based definitions toward a multi-dimensional, clinically operational model that integrates symptom patterns, temporal characteristics, physiological testing and psycho-social context. A central advance is the transition from categorical classification to dimensional phenotyping, recognizing the continuum and overlap inherent to DGBIs. The recalibration of diagnostic thresholds, most notably the re-introduction of abdominal discomfort and the requirement for symptom intermittency in irritable bowel syndrome, restores diagnostic sensitivity while improving mechanistic specificity. Rome V further introduces Rome Clinical Criteria, addressing the substantial sub-diagnostic population and enabling earlier, context-driven diagnosis in routine practice. Across organ systems, diagnostic definitions are refined to align more closely with underlying pathophysiology and clinical decision-making. This is exemplified by the integration of physiological frameworks in esophageal disorders, temporal stratification in gastroduodenal syndromes, the redefinition of centrally mediated abdominal pain and the incorporation of motor-sensory phenotyping in anorectal disorders. In parallel, Rome V emphasizes harm reduction in biliary disorders and introduces greater continuity across pediatric and adult frameworks. Despite these advances, challenges remain, including the absence of validated biomarkers, variability in global applicability and the need for further validation of new constructs. Overall, Rome V represents a shift from static diagnostic criteria to dynamic clinical pathways, providing a robust platform for mechanism-informed and increasingly individualized care in DGBIs.