Dr Lacy explains some of the key changes in criteria for disorders of gut-brain interaction, including irritable bowel syndrome and abdominal pain/discomfort, found in the recently published ROME V.

Brian Lacy, MD, is a professor of medicine at Mayo Clinic-Florida in Jacksonville, Florida.

ROME-5 Criteria (DGBI) Update—IBS Redefinition, Esophageal Testing, and New Diagnoses

• ROME-5 global criteria: Updated after 10 years to improve diagnostic clarity, standardize terminology, and emphasize patient-centered symptom integration; development grounded in scientific evidence including large randomized placebo-controlled trials and large epidemiologic studies.
• Irritable Bowel Syndrome: Definition now includes abdominal pain or discomfort (reintroduced); symptom frequency reduced to ≥3 days/month (not continuous); criteria better reflect real-world disease, with estimated prevalence ~8.5–9%.
• Chronic constipation criteria unchanged (≥2 of 6 symptoms). Functional diarrhea clarified to exclude constipation unless medication-induced. Functional bloating redefined by removing “distension” (distinct pathophysiology).
• Esophageal & upper GI disorders: Greater reliance on objective testing (high-resolution manometry, impedance pH monitoring) to distinguish functional heartburn (normal reflux testing, no symptom correlation) from reflux hypersensitivity (normal acid exposure with symptom sensitivity). Functional dyspepsia refined with clearer meal-related (PDS) vs epigastric pain (EPS) classification.
• New adult diagnosis: abdominal migraine (episodic ≥1 hour, symptom-free intervals weeks–months, migraine-like prodrome).
• Pediatric criteria add 14 new diagnoses and align anatomically with adult framework.

Welcome. My name is Brian Lacy. I'm a professor of medicine at the Mayo Clinic in Jacksonville, Florida, and I'm coming to you live from Chicago at Digestive Disease Week 2026. And what I'd like to discuss over the next few minutes is the release of the ROME-5 criteria. And the ROME-5 criteria, as many of our listeners know, are focused on disorders of gut-brain interaction, DGBI. And to set the stage, I think we have to ask why do we need new criteria? Why ROME-5? And I think there are a couple of great points. One is the last time criteria were released was 10 years ago in 2016 when we released the ROME-4 criteria. And these have been extensively used for research purposes and for clinical care as well. But after 10 years, there's been a lot of new information and it was time to update these criteria.

And there are 3 key aspects that as we develop the criteria across multiple anatomic regions that we wanted to focus on. One is we believe the new ROME-5 criteria provide clarity to these diagnoses. And in part, this clarity is the active communication. And by using the right terminology, the right definitions, clinicians can communicate well with each other and communicate well with patients, so that's clarity.

Number two, these guidelines were developed based on scientific evidence, and that's really important. These guidelines are not just expert opinions, but these guidelines are based on data from large randomized, placebo-controlled trials when available, and large epidemiology studies.

And lastly, what's really different about ROME 5 from ROME 4 is that a lot of this is really now patient-centered. We've always believed that patient is the important part of this whole process, but there's been a change over time. And when we really think about the new ROME-5 criteria for a number of different topics, you're going to see an emphasis on patient symptoms and how we can integrate those symptoms into clinical care and clinical improvement.

Okay. So with that in mind, let's get down to some of the basics and let's think about some of these changes for individual criteria. Certainly one of the most important topics for many of our patients is IBS, irritable bowel syndrome. And let's think about 3 key changes that occurred with ROME 5. Number one, the term abdominal discomfort has been reintroduced into the definition, and that's based on data from large epidemiologic studies. Matter of fact, the ROME epidemiology study involving nearly 77,000 patients across the world found that the presence of abdominal discomfort was associated with IBS. So now we think about abdominal pain or discomfort as part of the key definition for having irritable bowel syndrome. The next thing is that the presence of abdominal pain or discomfort has been reduced just 3 days per month. It does not have to be continuous. You don't need pain every day.  You need it on average three days per month. And again, that's based on the Rome epidemiology study. So this is data from across the globe.

Lastly, as I've kind of already mentioned, what I want to emphasize the important point is that pain does not have to be continuous. So for those 3 days, you don't need to have pain 3 days in a row. What this will do is kind of accurately reflect who IBS patients are in the world, and you're going to see the prevalence increase to about 8 1/2 to 9%, and that really reflects clinical care.

Okay. In terms of chronic constipation and other bowel disorder, there were no significant changes in our definition. So we still think about having at least 2 of 6 symptoms of straining or incomplete evacuation or difficult evacuation or infrequent bowel movements, but overall, no significant change from ROME 4 criteria.

And another bowel disorder I should mention is that of functional diarrhea. This is not very prevalent, but it is bothersome to patients. And one key change in the definition is we clarify kind of an obvious point, but we did clarify the point that constipation could not be present unless induced by medication. So functional diarrhea, patients with chronic, persistent, loose watery bowel movements, but no abdominal pain because otherwise they'd have IBS.

And the last change in terms of the bowel disorders chapter and the bowel disorders criteria was that a functional bloating and distension. This is a common problem. We recognize that about 5 to 6% of the population have problems with functional bloating. And we all know that bloating, that sensation of gas overlaps with IBS and chronic constipation and functional dyspepsia. But by itself, we now limit the definition to dysfunctional bloating. We remove the term distension. Distension is that physical manifestation. Frequently it represents an abnormal reflex. We call it abdominophrenic dyssynergia, and that's treated differently and is probably different pathophysiologically, so that's been removed.

All right, let's shift gears and let's talk about functional dyspepsia, which is one of the most common disorders of gut-brain interaction with a global prevalence of about 10%. There are a couple of big changes with functional dyspepsia. One is that we still distinguish epigastric pain syndrome and post-prandial distress syndrome. And we focus a little bit more in terms of postprandial distress in terms of symptoms related to meal ingestion. We kind of knew that before in ROME 4, but now it's much more clearly stated. These are meal-related symptoms of bothersome, and this is again where we're now focusing on the patient. Bothersome symptoms of fullness or early satiety, early satiation where you just eat a few bites, but you're so full already, or bothersome epigastric pain or epigastric burning.

So those are some of the key changes. In addition, we used to talk a lot about overlap of PDS postprandial distress syndrome and EPS, epigastric pain syndrome. That overlap is not quite as present with the new ROME-5 criteria because if you have bothersome meal-related meal ingestion symptoms, we're going to put you in the PDS category.

Let's shift gears again and let's talk about changes in the esophageal criteria for ROME-5. And there are a couple of changes. And one big change is that there's a little bit more reliance on objective testing, because we know it can be very difficult to kind of tease out some of these disorders of the esophagus, especially with regard to functional heartburn and reflux hypersensitivity. And so now we're emphasizing a little bit more the use of the Lyon criteria, the Lyon 2.0 criteria, which means that for many of these esophageal disorders, we're going to use objective testing, high resolution esophageal manometry and impedance pH monitoring, to tease these disorders out and really clearly separate them from gastroesophageal reflux disease. And that's important.

So as an example, remember that for functional heartburn where we now recommend testing, including manometry and impedance pH testing, these are patients who have symptoms of heartburn, substernal burning, that uncomfortable feeling of heartburn, but their impedance pH testing is normal without any relationship to episodes of acid reflux. In contrast, reflux hypersensitivity are those patients who undergo pH testing and although the pH test is normal, they're not having abnormal reflux. They sense these episodes of reflux very clearly. They are hypersensitive in the esophagus. So those are really the big changes for the esophageal section.

ROME 5 introduces 3 new adult diagnoses, and I want to focus on one, and that's abdominal migraine. So this has been well known in the pediatric literature and discussed in adults before, but we've never had distinct criteria. So a new diagnosis is that of abdominal migraine in adults.

And these are patients who have stereotypical episodes of abdominal pain that can be quite debilitating. They have to last for at least an hour. They should have episodes separated by weeks or months of not having symptoms, and that's important. And similar to having an abdominal migraine— and there does seem to be a relationship between abdominal migraine and central nervous system migraines— many of these patients may have a prodrome similar to having a central nervous system migraine, and this prodrome may include pallor, it may also include photophobia, and nausea and vomiting. So I think we're going to see some really interesting research in this field now that we have distinct criteria.

And that's another goal of ROME 5 is using these criteria to advance science, and this then stimulates research and maybe allows us to make better diagnoses in patients and better treatment.

Let's shift gears again and focus on another big change to the ROME-5 criteria, and that's in the pediatric group. I'm not a pediatric gastroenterologist, but there are some remarkable changes in that area that I think will change the field. And what I mean by that is that there are 14 new diagnoses in the pediatric criteria for ROME 5. And one of the big changes is that now the pediatric diagnoses have been broken down into anatomic regions similar to the adults. So there's an esophageal area, there's a gastric-duodenal area, there's a bowel disorder area. So this now mimics the adult criteria for ROME 5 in many ways, and this too will help advance science, and I think allow for better transition for the pediatric patients through adolescents to adults.

So coming here from Chicago at Digestive Disease Week 2026, a lot of excitement, a lot of buzz about the release of the ROME-5 criteria. Go online, look at the new criteria. I think this is going to be great for patient care. I think it's patient-centered. I think it's more integrative, and I think it's going to stimulate a lot of research in the field. Thanks so much for joining us.