Microbiota-immune-enteric nervous system interactions in functional constipation: a narrative review and...

Functional constipation (FC), particularly slow-transit constipation (STC), is a heterogeneous disorder of gut-brain interaction that responds poorly to conventional therapies. Accumulating evidence links the microbiota, mucosal immunity, and the enteric nervous system (ENS); their mechanistic integration remains incomplete. In this narrative review, we propose a Trigger-Gateway-Hub-Effector framework as a heuristic and hypothesis-generating model to organize fragmented evidence on microbial-to-immune-neural interactions. Within this framework, dysbiosis-associated microbial metabolites, including short-chain fatty acids, bile acids, methane-related pathways, and lipopolysaccharide, are considered potential upstream "Triggers" that may modulate epithelial and immune homeostasis. "Gateway" processes refer to epithelial barrier vulnerability and mucosal immune changes that may permit microbial or inflammatory signals to affect deeper intestinal compartments. At the "Hub" level, interactions among muscularis macrophages, mast cells, enteric glia cells, and neurons are proposed to integrate these signals and contribute to ENS-adjacent neuroimmune stress. These processes may converge on downstream "Effector" alterations, including neuronal vulnerability, maladaptive plasticity, and disruption of the interstitial cells of Cajal network, particularly in severe or refractory STC. However, there is currently limited direct evidence to support a continuous causal chain linking microbiome-derived signals to dysfunction of the enteroneural system. Many of the proposed mechanisms are inferred from preclinical studies or related gastrointestinal disorders. Therefore, this framework should be interpreted as a testable conceptual model rather than a confirmed pathogenic sequence. We further discuss the translational implications from a systems biology perspective, emphasizing evidence-weighted therapeutic interpretation, mechanism-guided stratification, and integrated microbial-immune-ENS assessment. Future human-centered studies combining multi-omic profiling, spatial tissue analysis, and objective neuromuscular readouts are needed to refine this model and inform precision-oriented therapeutic strategies for FC/STC.