The Rome V update includes criteria for the management of gut-brain axis disorders and a change in their nomenclature. The Rome Foundation has published the fifth edition of its criteria in Gastroenterology, providing the international diagnostic framework for chronic digestive disorders. “The main change is a shift toward less rigid criteria and the inclusion of integrated multidisciplinary treatment,” Ariadna Aguilar of the Digestive System Research Unit at Vall d’Hebron University Hospital in Barcelona, Spain, told El Médico Interactivo, part of Medscape’s Professional Network.

Aguilar noted that, for the first time, dietary interventions aimed at patients’ psychological well-being have been included, without compromising the rigor of the content, which is always based on the best available scientific evidence.

Some specific new developments include the addition of three new diagnoses: inability to belch or retrograde cricopharyngeal dysfunction, adult abdominal migraine, and anorectal sensory dysfunction. The categories in the pediatrics section have also been reorganized, shifting from an age-based classification in Rome IV to a classification by anatomical regions in Rome V, following the same methodology as in the adult classification. Finally, perhaps the most important change for our day-to-day practice is the distinction between the much stricter diagnostic criteria intended for research and those applicable in clinical practice, which allow for the inclusion of the clinician’s professional judgment in the diagnosis, rather than relying on a specific percentage.

Terminological Change

For Aguilar, the most visible change is terminological. Rome IV had already begun the transition away from using the term “functional” to refer to chronic digestive disorders. Given the growing understanding in recent decades of the pathophysiology of these conditions, it proposes referring to them as gut-brain axis disorders. Thus, for example, “functional constipation” is no longer used; it is now referred to as “chronic constipation.”

In her opinion, the change likely to have the greatest practical impact is the redefinition of irritable bowel syndrome (IBS). The new criteria lower the frequency threshold and reintroduce the term “discomfort” — which was already present in Rome III — to replace the term “pain.” In other words, a patient experiencing discomfort can now be diagnosed with IBS, which increases the diagnostic sensitivity of the criteria.

Prevalence

Regarding prevalence, the gastroenterologist noted that “it is higher than is generally perceived. The Rome Foundation Global Epidemiology Study estimates adult prevalence at around 40%, including in Spain. However, it should be clarified that these figures still come from studies using Rome IV criteria, as there are not yet any epidemiologic data generated using Rome V.”

Thus, IBS remains the most common and most studied condition, with an estimated prevalence of between 5% and 10% of the general population. It is followed in frequency by functional dyspepsia, chronic constipation, and functional abdominal distension/bloating.

As Aguilar emphasized, it is important to note that the new Rome V classification is a refinement of the diagnostic criteria for clinical entities that have been established for years; in other words, new pathological entities are not being classified; these are the same disorders.

Rome V reinforces an idea already suggested by Rome IV: The diagnosis should be positive, not one of exclusion. In most patients who meet the criteria and show no warning signs, diagnostic tests should be targeted and limited based on the pre-test probability of other diseases, such as inflammatory bowel disease, celiac disease, microscopic colitis, etc.

As she noted, “this does not mean disregarding clinical judgment: Rome V does not incorporate biomarkers nor does it eliminate the need for a detailed medical history, targeted physical examination, and selective diagnostic tests, but it can help reduce repetitive, low-yield testing in patients who have already been evaluated and guide symptom-targeted interventions earlier.”

Those Who Benefit Most

Aguilar highlighted that the patients most likely to benefit from the new criteria are those with infrequent symptoms — meaning those who don’t have symptoms every day or whose symptoms are very mild. In IBS, for example, this would include patients who report more discomfort than actual pain.

“These patients will have the opportunity to receive a diagnosis from us with certainty and without doubt, allowing us to put a name to their symptoms, understand their pathophysiology, alleviate uncertainty, and stop performing unnecessary tests,” she added.

As for terminology, the phasing out of the term “functional” reduces the social stigma experienced by some patients, who interpret the term “functional” as synonymous with “not real” or a catch-all label, which increases mistrust in the diagnosis.

“The use of clinical language that validates their symptoms as real without the need to find a structural lesion is fundamental to the doctor-patient relationship, fostering a strong therapeutic alliance and achieving better clinical outcomes — which is, after all, our goal,” explained Aguilar.

To implement the changes outlined in the update, it will be necessary to validate the new criteria in diverse populations, analyze their impact on the prevalence of diagnoses, and determine whether future clinical trials using the new Rome V criteria alter the applicability of the available evidence.

In practice, “implementation will involve updating scientific society guidelines, targeted continuing education, and a gradual adaptation of existing diagnostic algorithms, rather than a complete break with current practice,” Aguilar concluded.

Aguilar declared no conflict of interest.

This story was translated from El Médico Interactivo, part of the Medscape Professional Network.