The Rome criteria, first published in 1994 and currently in their fourth iteration, are widely considered to be the gold standard symptom-based criteria to diagnose disorders of gut-brain interaction (DGBI), formerly known as functional gastrointestinal diseases [1]. To inform the upcoming Rome V criteria, due for publication in 2026, the Rome Foundation analysed the effects of modifying symptoms (e.g., pain and discomfort) and their relative frequency on the population prevalence of irritable bowel syndrome (IBS) [2, 3].

In a three-year UK-based prospective study, Goodoory et al. [4] published the performance of two of the Rome Foundation's proposed modifications to the Rome IV IBS diagnostic criteria, the original Rome IV criteria, and the Rome III criteria, using a reference standard as a comparison (Table 1). Consistent with previous work [7], the Rome IV criteria were more specific (85.1% vs. 80%) than Rome III, but less sensitive (82.1% vs. 92.6%). Modifying the criteria by relaxing the frequency of abdominal pain to three days per month, from one day per week, led to the best performance (sensitivity 90.2%, specificity 85.1%, positive likelihood ratio 6.06, and negative likelihood ratio 0.11) (Table 1, second modification to the Rome IV criteria). These data suggest that the developers of the Rome V diagnostic criteria for IBS should prioritise pain over discomfort and consider relaxing abdominal pain from at least one day per week to three days per month.

This paper lends support to the initiatives of the Rome Foundation [2] and offers guidance for future revisions of the diagnostic criteria for IBS, albeit to an extent. Indeed, given that the study was conducted in a tertiary referral setting enriched with patients who underwent screening for organic diseases in primary care, the specificity and sensitivity of the Rome III and IV criteria may not accurately reflect those observed in community and general gastroenterology settings, particularly in countries outside the UK. Since the Roman Empire's limited global perspective contributed to its decline, the developers of the Rome V criteria for IBS should account for different symptom patterns and their relative impact across intercontinental populations. Compared with Rome III, making abdominal pain a mandatory requirement for a Rome IV IBS diagnosis and increasing its frequency threshold appears to have led to a more significant reduction in the population prevalence of IBS in Asia—specifically Japan [9.3% vs. 2.2%] and China [7.4% vs. 2.3%] [3]—compared to North America and Europe (9.2% vs. 4.6%) [8]. Although symptoms of bloating and discomfort are arguably more relevant to persons in Asia [9], factor analysis has confirmed the global applicability of the Rome IV criteria [10], and a similar intercontinental analysis should be undertaken to ensure Rome V's survival and international relevance.

Goodoory et al. [4] have provided stonemasons with an additional brick in their quest to rebuild Rome. Only time will tell how pain, discomfort or symptom frequency will shape the next Rome iteration and how such refinements may enhance patients' quality of life and support access to evidence-based treatment.