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.