Gastrointestinal endoscopy for physiological assessment in functional gastrointestinal disorders: a perspective

The diagnosis of functional gastrointestinal disorders, now conceptualized as disorders of gut-brain interaction (DGBI), has long relied on symptom-based criteria. Gastrointestinal endoscopy, meanwhile, has been largely confined to the exclusion of organic pathology. This exclusionary logic has led to a systematic underestimation of the diagnostic value embedded in endoscopically normal findings. Here we propose a fundamental repositioning of the endoscope from a static morphological exclusion tool into a dynamic physiological assessment platform. By integrating real-time intraluminal functional imaging, optical biopsy of mucosal microarchitecture, neuro-immune fluorescence molecular imaging, and intraluminal environmental monitoring, this platform enables the in situ capture of key pathophysiological parameters-including gastrointestinal sensorimotor function, mucosal barrier integrity, and immune activation status. Establishing such a "functional endoscopy" assessment framework may help bridge the traditional divide between structural and functional disease. It could also facilitate future precision endoscopic phenotyping of DGBI based on underlying pathophysiological mechanisms.