digest
Short Summary
Main recommendation: For centrally mediated abdominal pain syndrome (CAPS), Dr. Kirsten Tillisch recommends minimal further workup and avoiding surgery, focusing instead on a stepwise, holistic treatment plan built with the patient that targets comorbidities such as insomnia, depression, and anxiety along with the pain. CAPS is a centrally mediated pain condition in which an encoded memory of pain is replayed through the brain, and treatment aims to improve function in the moment rather than find a single origin of the pain.
Key Points
- CAPS is defined using Rome criteria: continuous pain unrelated to physiologic GI events, pain that limits daily functioning across multiple life domains, pain that is not feigned, and no better explanation from another structural or functional GI disorder or medical condition.
- Associated but non-required behaviors include seeking many diagnostic tests and frequent care from multiple providers, urgent reporting of intense symptoms, minimizing psychosocial contributors, and focusing on complete relief rather than stepwise improvement.
- Proposed mechanism: impaired central pain modulation, amplified by hypervigilance, catastrophizing, and fear-avoidance, with possible abdominal wall allodynia; comorbid headaches, back pain, fibromyalgia, and other somatic pains feed into the same brain pathway.
- According to Dr. Tillisch, depression is the most common mental health disorder in CAPS, with anxiety and PTSD also common.
- According to Dr. Tillisch, surgery can increase symptoms in about a third of people with chronic unexplained abdominal pain, and in a small study of 44 individuals it helped no one; in many cases surgery became the trigger for CAPS.
Details Worth Noting
- Concrete instructions:
- Limit the workup to what is needed: evaluate for structural disease and address alarm symptoms, and avoid surgical intervention where possible.
- Begin with the patient-physician relationship: ask the patient how you can be helpful, and set expectations, including that the cause of the pain may never be found.
- Ask the patient to set aside the search for the pain's origin and focus first on feeling better in the moment through a stepwise, holistic approach.
- Link treatments to comorbidities: choose interventions that can help pain alongside depression, anxiety, and sleep, and build the plan together with the patient, with shared responsibility.
- Example given: mindfulness-based stress reduction, an evidence-based chronic pain modality that also may help depression, anxiety, sleep, and loneliness, and is a group intervention. Dr. Tillisch notes that simply prescribing meditation to a patient who refuses medication will not work.
- Consider a neuromodulator later if the patient becomes willing, and involve a team such as an integrative program or vetted community providers.
- The case patient, a 32-year-old man, had seven years of severe abdominal pain, normal imaging and endoscopy, a gallbladder removal that worsened symptoms, and failed or poorly tolerated trials of PPIs, NSAIDs, opiates (later tapered off), diets, trigger point injections, and neuromodulators (pregabalin caused palpitations).
- The speaker notes the patient's pain did not change with eating, food type, or bowel movements, and the patient reported pain up to 10/10 at worst, often when lying down at bedtime.
Bottom Line
CAPS is best approached as a chronic pain loop that needs holistic, collaborative care addressing sleep, mood, and overall function, rather than a search for a surgical or single structural cause.
