Practical management of the patient with a centrally mediated disorder of gastrointestinal pain

A minority of patients with a disorder of gut–brain interaction present with severe, chronic abdominal pain with no consistent association with eating or defecation. These conditions—centrally mediated abdominal pain syndrome (CAPS) and narcotic bowel syndrome (NBS)—are classified as centrally mediated disorders of gastrointestinal pain. CAPS is characterised by continuous or nearly continuous abdominal pain unrelated to physiological events, while NBS involves worsening abdominal pain during ongoing or escalating opioid use. These conditions are nociplastic with an altered central pain processing despite no evidence of active tissue damage or structural disease. Central sensitisation, opioid-induced hyperalgesia and glial activation are proposed as key mechanisms involved. Although CAPS and NBS are uncommon, patients often seek healthcare due to the intensity of abdominal pain, as well as associated somatic and psychological symptoms. This review outlines the clinical features, diagnostic approach and management strategies for CAPS and NBS. It also highlights the importance of patient-centred communication, validation of symptoms and integration of the biopsychosocial model in the management of these disorders. Greater awareness and structured management may help reduce diagnostic delay, healthcare burden and long-term morbidity for these patients.