Systematic review: interventions for abdominal pain management in inflammatory bowel disease

Abdominal Pain in Inflammatory Bowel Disease-Epidemiology, Pathophysiology, and Management: A Narrative Review

Abdominal pain is a major symptom of inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis, and has a significant impact on patients' quality of life. Given the evolving understanding of IBD pathology and management strategies, there is an urgent need to review the recent research findings. In this review, we have analyzed the epidemiology, pathophysiology, and management of abdominal pain in IBD over the past decade. We draw on the current literature and highlight emerging trends, challenges, and advances in this field. By synthesizing key findings, this review provides insights into the complex interplay between abdominal pain, disease progression, and therapeutic interventions for IBD.

Factors associated with chronic abdominal pain in patients with inflammatory bowel disease in remission: A pilot cross-sectional study

BACKGROUND

Patients (20%-50%) with inflammatory bowel disease (IBD) experience chronic abdominal pain during remission. The clinical features of IBD patients with abdominal pain during remission remain poorly characterized. This cross-sectional pilot study aimed to assess patient recruitment, adherence, and feedback to optimize questionnaires for future use and to determine the clinical features that distinguish IBD patients in remission with and without abdominal pain.

METHODS

Online validated questionnaires about disease activity, symptoms, and psychological factors were sent to participants of the UK National Institute for Health and Care Research (NIHR) IBD BioResource, which is a national research platform consisting of re-callable IBD patients designed to expedite research into Crohn's and colitis. Inclusion/exclusion criteria of the IBD BioResource main cohort were applied. Descriptive and inferential statistics were applied to participants in remission. p-values ≤0.01 were considered significant.

KEY RESULTS

A total of 2050 patients were approached; 291 (14.2%) of these agreed to participate. In 35 patients, technical problems, length, and poor understanding of the relevance of some questionnaires affected completion as confirmed by feedback. In total, 244 patients were full responders with 122 (50%) in remission; 33 (27%) of these had chronic abdominal pain. Comparison of those with versus without (n = 89) chronic abdominal pain yielded higher scores in patients with pain for the following: somatization (p < 0.001); gastrointestinal symptoms rating scale score (p = <0.001); highly sensitive person scale (p = 0.007); catastrophizing score (p = 0.010). Trends were observed for azathioprine use (p = 0.021); coping resources inventory health in general (p = 0.046); neuroticism (p = 0.019); and poor sleep (p = 0.03).

CONCLUSIONS & INFERENCES

Differences in symptoms and psychological characteristics exist between IBD patients in remission with and without abdominal pain. Confirmation of findings in larger studies may facilitate development of personalized chronic pain treatments for IBD patients.

Risk Factors for Persistent Postoperative Opioid Use After Surgery for IBD: An Observational Cohort Study

BACKGROUND

Patients with IBD are at increased risk of persistent opioid use, wherein surgery plays an important role.

OBJECTIVE

Identify risk factors for persistent postoperative opioid use in patients with IBD undergoing GI surgery and describe in-hospital postoperative opioid treatment.

DESIGN

This was a retrospective observational cohort study. ORs for persistent postoperative opioid use were calculated using preoperative and in-hospital characteristics, and in-hospital opioid use was described using oral morphine equivalents.

SETTING

This study was conducted at a university hospital with a dedicated IBD surgery unit.

PATIENTS

Patients who underwent surgery for IBD from 2017 to 2022 were included.

MAIN OUTCOME MEASURES

Our main outcome measure was persistent postoperative opioid use (1 or more opioid prescriptions filled 3-9 months postoperatively).

RESULTS

We included 384 patients, of whom 36 (9.4%) had persistent postoperative opioid use, but only 11 (2.9%) of these patients were opioid naive preoperatively. We identified World Health Organization performance status >1 (OR 8.21; 95% CI, 1.19-48.68), preoperative daily opioid use (OR 12.84; 95% CI, 4.78-35.36), psychiatric comorbidity (OR 3.89; 95% CI, 1.29-11.43) and in-hospital mean daily opioid use (per 10 oral morphine equivalent increase; OR 1.22; 95% CI, 1.12-1.34) as risk factors for persistent postoperative opioid use using multivariable regression analysis.

LIMITATIONS

Our observational study design and limited sample size because of it being a single-center study resulted in wide CIs.

CONCLUSIONS

We identified risk factors for persistent postoperative opioid use in patients undergoing surgery for IBD. Results indicate a need for optimization of pain treatment in patients with IBD both before and after surgery. These patients might benefit from additional opioid-sparing measures. See Video Abstract.

FACTORES DE RIESGO EN LA ADMINISTRACION DURADERA DE OPIOIDES EN EL POSTOPERATORIO EN CASOS DE CIRUGA POR ENFERMEDAD INFLAMATORIA INTESTINAL ESTUDIO OBSERVACIONAL DE COHORTES

ANTECEDENTES:Los pacientes con enfermedad inflamatoria intestinal (EII) tienen un mayor riesgo de recibir opioides de manera duradera, casos donde la cirugía juega un papel importante.OBJETIVO:Identificar los factores de riesgo en la administración duradera de opioides en el post-operatorio de cirugía gastrointestinal en casos de EII y describir el tratamiento intra-hospitalario con los mismos.DISEÑO:Estudio observacional retrospectivo de cohortes. La relación de probabilidades (odds ratio - OR) en la adminstracion duradera de opioides post-operatorios fué calculada utilizando las características pré-operatorias y hospitalarias, donde la administración de opioides intra-hospitalarios fué descrita con la utilización de equivalentes de morfina oral.AMBIENTE:Estudio realizado en un hospital universitario con una unidad de cirugía dedicada a la EII.PACIENTES:Se incluyeron todos los pacientes sometidos a cirugía por EII entre 2017 y 2022.PRINCIPALES MEDIDAS DE RESULTADO:Nuestra principal medida de resultado fué la administración post-operatoria duradera de opioides (≥1 receta completa de opioides entre 3 y 9 meses después de la operación).RESULTADOS:Incluimos 384 pacientes, de los cuales 36 (9,4%) recibieron opioides de manera duradera en el post-operatorio, de los cuales solamente 11 pacientes (2,9%) no habían recibido opioides antes de la operación. Identificamos el estado funcional de la OMS > 1 (OR 8,21, IC 95% 1,19-48,68), el uso diario de opioides pré-operatorios (OR 12,84, IC 95% 4,78-35,36), los casos de comorbilidad psiquiátrica (OR 3,89, IC 95% 1,29-11,43) y el uso medio diario de opioides en el hospital (por cada aumento de 10 equivalentes de morfina oral) (OR 1,22, IC del 95%: 1,12-1,34 como factores de riesgo para la administración de opioides de manera duradera en el post-operatorio mediante el análisis de regresión multivariable.LIMITACIONES:Nuestro diseño de estudio observacional y el tamaño de la muestra limitada debido a que fue un estudio en un solo centro, dando como resultado intervalos de confianza muy amplios.CONCLUSIONES:Se identificaron los factores de riesgo en la administración duradera de opioides en el post-operatorio de cirugía gastrointestinal en casos de EII. Los resultados demuestran la necesidad de optimizar el tratamiento del dolor en pacientes con EII, tanto antes como después de la cirugía. Estos pacientes podrían beneficiarse de medidas adicionales de ahorro de opioides. (Traducción-Dr. Xavier Delgadillo).

Review article: A practical approach to persistent gastrointestinal symptoms in inflammatory bowel disease in remission

BACKGROUND

Persistent gastrointestinal symptoms are prevalent in adult patients with inflammatory bowel disease (IBD), even when endoscopic remission is reached. These symptoms can have profound negative effects on the quality of life of affected patients and can be difficult to treat. They may be caused by IBD-related complications or comorbid disorders, but they can also be explained by irritable bowel syndrome (IBS)-like symptoms.

AIMS

To provide a practical step-by-step guide to diagnose and treat persistent gastrointestinal symptoms in patients with IBD in remission via a personalised approach.

METHODS

We scrutinised relevant literature on causes, diagnostics and treatment of persistent gastrointestinal symptoms (abdominal pain or discomfort, bloating, abdominal distension, diarrhoea, constipation and faecal incontinence) in patients with IBD in remission.

RESULTS

A graphical practical guide for several steps in diagnosing, identifying potential triggers and adequate treatment of persistent gastrointestinal symptoms in IBD in remission is provided based on supporting literature. The first part of this review focuses on the diagnostic and treatment approaches for potential IBD-related complications and comorbidities. The second part describes the approach to IBS-like symptoms in IBD in remission.

CONCLUSIONS

Persistent gastrointestinal symptoms in IBD in remission can be traced back to potential pathophysiological mechanisms in individual patients and can be treated adequately. For both IBD-related complications and comorbidities and IBS-like symptoms in IBD in remission, pharmacological, dietary, lifestyle or psychological treatments can be effective. A systematic and personalised approach is required to reduce the burden for patients, healthcare systems, and society.

Older Adult-Onset of Inflammatory Bowel Diseases Is Associated With Higher Utilization of Analgesics: A Nationwide Cohort Study

INTRODUCTION

Patients with inflammatory bowel diseases (IBD) commonly require analgesic medications to treat pain, which may be associated with complications. We examined trends of analgesic use according to age at IBD onset.

METHODS

This nationwide cohort study included adults diagnosed with IBD between 1996 and 2021 in Denmark. Patients were stratified according to their age at IBD onset: 18-39 years (young adult), 40-59 years (adult), and older than 60 years (older adult). We examined the proportion of patients who received prescriptions for analgesic medications within 1 year after IBD diagnosis: strong opioids, tramadol, codeine, nonsteroidal anti-inflammatory drugs, and paracetamol. Multivariable logistic regression analysis was performed to examine the association between age at IBD onset and strong opioid prescriptions and the composite of strong opioid/tramadol/codeine prescriptions.

RESULTS

We identified 54,216 adults with IBD. Among them, 25,184 (46.5%) were young adults, 16,106 (29.7%) were adults, and 12,926 (23.8%) were older adults at IBD onset. Older adults most commonly received analgesic prescriptions of every class. Between 1996 and 2021, strong opioid, tramadol, and codeine prescriptions were stable, while paracetamol prescriptions increased and nonsteroidal anti-inflammatory drug prescriptions decreased. After multivariable logistic regression analysis, older adults had higher adjusted odds of receiving strong opioid prescriptions (adjusted odds ratio 1.95, 95% confidence interval 1.77-2.15) and the composite of strong opioid/tramadol/codeine prescriptions (adjusted odds ratio 1.93, 95% confidence interval 1.81-2.06) within 1 year after IBD diagnosis compared with adults.

DISCUSSION

In this nationwide cohort, older adults most commonly received analgesic prescriptions within 1 year after IBD diagnosis. Additional research is needed to examine the etiology and sequelae of increased analgesic prescribing to this demographic.

Making sense of pain in inflammatory bowel disease (IBD): A qualitative study

OBJECTIVES

Inflammatory bowel disease (IBD) is a chronic, gastrointestinal tract condition, in which pain is one of the most widespread and debilitating symptoms, yet research about how individuals make sense of their IBD pain is lacking. The current study aimed to explore how individuals with IBD understand their pain.

METHODS

Twenty participants, recruited via the Crohn's & Colitis UK charity, were interviewed about their understanding of their IBD pain using the Grid Elaboration Method that elicits free associations on which it invites elaboration. Thematic analysis was used to organise transcribed verbatim data.

RESULTS

Three related themes - making sense of my pain, navigating my care and support and it takes its toll - comprising seven sub-themes, illustrated the ways in which participants made sense of pain experientially, multi-dimensionally, and in the broader context of IBD and its symptoms. The psychological impact of pain was evident across all interviews.

CONCLUSIONS

The findings are consistent with other research in IBD pain, demonstrating the importance of pain in IBD. Sense-making underpins both emotional and practical responses to pain and ideally is constructed as an integral part of clinical care of IBD.

Factors influencing the quality of life in inflammatory bowel disease: A comprehensive review

Inflammatory bowel disease (IBD) is a group of chronic relapsing disorders, including Crohn's disease (CD) and ulcerative colitis (UC), which affects an increasing number of people worldwide. In the last few decades, the scientific world has witnessed many developments in IBD management by controlling debilitating symptoms and remaining in remission for more protracted periods. Even so, we still have a large population suffering from active IBD. An individual's quality of life (QoL) can be severely affected by IBD, like any other chronic illness. In this article, we have reviewed factors influencing the QoL in IBD patients, including chronic pain, diet, physical activity, and psychological factors like depression, anxiety, and stress symptoms. We also discussed the mechanisms of diet-microbial-immune system interaction, currently available dietary therapies for active CD and UC, and early psycho-social interventions that can reduce the disease burden and improve QoL in IBD patients.

A qualitative analysis of stress experiences and coping strategies in adolescents with Crohn's disease

BACKGROUND

In this study, we investigated the coping mechanisms and stress perceptions of adolescent patients with Crohn's disease.

METHODS

Using semi-structured face-to-face interviews, we conducted an extensive qualitative study of the disease perceptions, stress experiences, and corresponding coping mechanisms in adolescent patients with Crohn's disease. We used Colaizzi content analysis to synthesize the themes.

RESULTS

The two main themes in this study were inappropriate coping mechanisms and physical and psychological stress. The primary initiators of physical and psychological stress in adolescents with Crohn's disease were weak disease perception, symptom distress, negative emotions, lack of support, and multiple stressors. The decrease in self-management and self-control induced by the initiators led to changes in cognition, emotions, and attitudes, which subsequently led to poor coping behavior.

CONCLUSION

Adolescents with Crohn's disease can better combat the condition by implementing appropriate coping strategies. Their mental health should be given attention, and a multidisciplinary team should be assembled to provide them with supportive care.

Chronic abdominal pain in inflammatory bowel disease: a practical guide

Pain is common in inflammatory bowel disease (IBD), yet many patients feel their pain is not addressed by healthcare professionals. Listening to a patient's concerns about pain, assessing symptoms and acknowledging the impact these have on daily life remain crucial steps in addressing pain in IBD. While acute pain may be effectively controlled by pain medication, chronic pain is more complex and often pharmacological therapies, particularly opioids, are ineffective. Low-dose tricyclic antidepressants and psychological approaches, including cognitive-behavioural therapy, have shown some promise in offering effective pain management while lifestyle changes such as a trial of low-fermentable oligosaccharides, disaccharides, monosaccharides and polyols diet in those with overlapping irritable bowel syndrome may also reduce pain. Patients benefit from a long-term, trusting relationship with their healthcare professional to allow a holistic approach combining pharmacological, psychological, lifestyle and dietary approaches to chronic pain. We present a practical review to facilitate management of chronic abdominal pain in IBD.

Research hotspots and trend analysis of abdominal pain in inflammatory bowel disease: a bibliometric and visualized analysis

Aims: The study aimed to provide a bibliometric and visual analysis of research on abdominal pain in inflammatory bowel disease and discuss the current status, research hotspots, and future developments. Methods: We used the Web of Science Core Collection to comprehensively search the literature on abdominal pain-related research in IBD published between 2003 and 2022. The bibliometric and visual analysis was performed through CiteSpace, VOSviewer software, R language, and the bibliometric online analysis platform, including authors, institutions, countries, journals, references, and keywords in the literature. Results: A total of 3,503 relevant articles are included, indicating that the number of articles in this field has increased in recent years. The United States leads the way with a dominant position in terms of article output, followed by China and JAPAN. United States (967 articles), University of Calgary (98 articles), and World Journal of Gastroenterology (127 articles) are the top publishing countries, institutions, and journals, respectively; keyword analysis shows that gut microbiota, depression, stress, visceral hypersensitivity, and multidisciplinary approach are the hot spots and trends in this research area. Conclusion: Abdominal pain-related studies in IBD have received increasing attention in the past two decades. This study provides the first bibliometric analysis of papers in this research area using visualization software and data information mining. It provides insights into this field's current status, hot spots, and trends. However, many outstanding issues in this research area still need further exploration to provide a theoretical basis for its clinical application.

Pharmacotherapy for gastric and intestinal cramping pain: ‎ current and emerging therapies

INTRODUCTION

Acute gastrointestinal cramping pain (GICP) is a debilitating condition that affects many people worldwide, significantly reducing their quality of life. As such, prompt treatment is crucial.

AREAS COVERED

This article will explore relevant literature from databases such as PubMed, Scopus, Google Scholar, Cochrane Library, and Web of Science. Additionally, we searched ClinicalTrials.gov and the WHO ICTRP database for the latest clinical trials.

EXPERT OPINION

Consensus dictates that antispasmodics such as hyoscine-N-butyl bromide and mebeverine should be the primary treatment for GICP. If these prove ineffective, patients can switch to an antispasmodic with a different mode of action or add acetaminophen/NSAIDs for more severe cases. Currently, several antispasmodics are undergoing clinical trials, including drotaverine, alverine, pinaverium, otilonium bromide, fenoverine, tiropramide, otilonium bromide, trimebutine, and peppermint oil. Well-designed head-to-head studies are necessary to evaluate current antispasmodics' safety, efficacy, pharmacokinetic, and pharmacoeconomics profiles. Recent studies have shown that fixed-dose combinations of antispasmodics + NSAIDs or two different antispasmodics can improve patient compliance and synergistically reduce GICP. Therefore, it is recommended that the global availability and accessibility of these products be enhanced.

Content of Telephone Consultations of Patients With Inflammatory Bowel Disease: A Single-Center Descriptive Study

This study aimed to analyze the specific contents of telephone consultations of patients with inflammatory bowel disease. A medical record survey was conducted at a clinic in Japan for 1 year. Telephone consultation sheets recorded by nurses for calls with the patients or their relatives were reviewed. Content analysis was used to summarize the telephone consultation content. Consultations were categorized into 8 categories. Coding was conducted by 2 independent researchers. Concordance rates were evaluated using kappa coefficients. We analyzed 476 sheets. A total of 229 participants consulted the clinic at least once. The mean number of consultations per person was 2.1. Of these patients, 96 (40.9%) had ulcerative colitis. The kappa coefficient was 0.89. The most frequent consultation was "Consultation on worsening health: Inflammatory bowel disease is likely to have worsened" (42.0%). The second most frequent response was "Consultation or progress report on a worsening health condition: The disease is unlikely to have worsened" (19.8%). For consultations related to worsening the disease, it would be useful to assess symptoms over the phone using a disease activity index to ascertain the degree of worsening and to develop a screening tool for determining whether patients can continue remote support or require face-to-face consultation.

Lafoensia pacari alleviates intestinal damage by modulating cyclooxygenase-2: In silico and in vivo evaluation in a colitis model

BACKGROUND

Inflammatory bowel diseases (IBD) are a worldwide health problem and mainly affect young people, consequently affecting the workforce. Available treatments are often associated with side effects, and new therapeutic options are needed. For centuries, plants have represented important substrates in the field of drug development. Lafoensia pacari (L. pacari) is a plant whose pharmaceutical potential has been described, and may have biological activity relevant to the treatment of IBD symptoms.

AIM

To investigate the activity of keto-alcoholic extracts of L. pacari with respect to ameliorating the inflammatory and nociceptive symptoms of acute experimental colitis in mice.

METHODS

Keto-alcoholic extracts of L. pacari leaves and bark were administered to male and female Swiss mice weighing 25 g to 30 g (n = 8 male mice and n = 8 female mice). The effect of these extracts was observed in an acetic acid-induced acute experimental model of colitis with regard to antinociception/analgesia and inflammatory tissue damage. Recorded macroscopic indices included the Wallace score and the colon weight obtained using a precision scale. Mechanical hyperalgesia was determined using an electronic analgesimeter. Behavior related to overt pain was determined by quantifying the number of writhing instances within 20 min of administration of acetic acid. Molecular docking was performed using human and murine cyclooxygenase-2 (COX-2) with 3 flavonoids (ellagic acid, kaempferol, and quercetin) on the AutoDock Vina software. Analysis of variance followed by Tukey’s posttest was used with P < 0.05 indicating significance.

RESULTS

In this murine model of colitis, administration of extracts from L. pacari ameliorated acetic acid-induced writhing and colitis-associated inflammatory pain. These improvements may be attributable to the reduction in edema, inflammation (e.g., ulcers, hyperemia, and bowel wall damage), and the intensity of abdominal hyperalgesia. The keto-alcoholic extracts of L. pacari leaves and bark administered at a dose of either 100 mg/kg or 300 mg/kg significantly reduced the number of writhing events when compared to the negative control (P < 0.05). Additionally, extracts of L. pacari bark also performed better than Dipyrone. Leaf extracts administered at 10 mg/kg, 30 mg/kg, and 100 mg/kg and bark extracts administered at 30 mg/kg significantly reduced or prevented the development of edema in the colon of treated mice, while mesalazine did not. Moreover, using molecular docking, we observed that the flavonoids present in L. pacari extracts bind to COX-2, an event not unique to ellagic acid.

CONCLUSION

The results of this study demonstrate a potential novel application of L. pacari extracts for the reduction of inflammation and promotion of antinociception/analgesia as demonstrated by our findings in a murine model of colitis. These findings were also corroborated by in silico analyses, and suggest that L. pacari extracts may be a promising therapeutic agent in the treatment of IBD.

Randomised clinical trial: Psychological intervention improves work productivity and daily activity by reducing abdominal pain and fatigue in Crohn's disease

BACKGROUND

Chronic abdominal pain and fatigue are characteristics of Crohn's disease (CD) and contribute to functional impairments.

AIMS

To examine whether CD-tailored cognitive-behavioural and mindfulness intervention (COBMINDEX) is effective in reducing abdominal pain and fatigue in patients with CD and whether changes in abdominal pain and fatigue mediate any beneficial effects of COBMINDEX on impairments in work productivity and daily activities.

METHODS

This is a secondary analysis of a parallel-group multicentre randomised controlled trial. Patients with mild-to-moderate CD (n = 142) were randomised into either intervention group receiving COBMINDEX, or control group receiving treatment-as-usual for 3 months followed by COBMINDEX. Complete data were collected from 120 patients (34.0 ± 10.7 years, 62.5% female, intervention = 60, control = 60). Analysis of covariance assessed group differences in 3-month follow-up scores, controlling for baseline scores. Multiple parallel mediation analysis assessed the proposed mechanisms for the entire sample.

RESULTS

The intervention group demonstrated significantly lower levels of abdominal pain (F = 17.46, p < 0.001, η² _p  = 0.13), fatigue (F = 7.26, p = 0.008, η² _p  = 0.06) and impairments at work (F = 4.82, p = 0.032, η² _p  = 0.07) and daily activities (F = 6.26, p = 0.014, η² _p  = 0.05), compared with treatment-as-usual. Moreover, changes in abdominal pain and fatigue significantly mediated the beneficial effects of COBMINDEX on patients' work productivity (b = -9.90, SE = 2.86, 95% CI: -16.11 to -4.94) and daily activities (b = -9.65, SE = 1.91, 95% CI: -13.77 to 6.35), independent of changes in disease activity.

CONCLUSIONS

COBMINDEX is effective at reducing abdominal pain and fatigue in patients with CD, which in turn leads to improvement in functioning. Clinicians should incorporate screening for severe abdominal pain and fatigue and consider offering cognitive-behavioural and mindfulness training.

CLINICALTRIALS

gov, Number: NCT05085925. Ministry of Health in Israel (https://my.health.gov.il/CliniTrials/Pages/MOH_2020-02-24_008721.aspx).

Appraisals of Pain in Pediatric Inflammatory Bowel Disease: A Qualitative Study With Youth, Parents, and Providers

Background

Pain is a predominant symptom of inflammatory bowel disease (IBD), and is influenced by cognitive, emotional, and behavioral factors. The cognitive-affective model of symptom appraisal (CAMSA) has been used to understand how youth view symptoms in chronic conditions. We sought to (1) determine how youth with IBD and their parents appraise pain, and how their perspectives fit within CAMSA, and (2) explore health care providers' understanding and communication about pain.

Methods

Participants included 19 youth ages 10-17 years with chronic IBD pain and their parents, and 5 IBD providers from a gastroenterology clinic. Separate semi-structured qualitative interviews with youth, parents, and providers were conducted. Interview prompts were adapted from CAMSA, previous studies of pediatric pain and symptom monitoring, and a qualitative study in adults with IBD pain. Interviews were analyzed according to principles of reflexive thematic analysis.

Results

Three key components of CAMSA (IBD Threat, Fear/Worry, and Biased Attending) were identified in youth and parent dyads. Some youth showed Biased Attending, including difficulty disengaging, while other youth simply monitored pain. The overarching theme for provider interviews was Gastroenterologists view pain as a secondary (rather than primary) treatment issue.

Conclusions

CAMSA is potentially applicable to pain appraisal in youth with IBD and their parents. When health care providers communicate about pain, they should consider how symptom uncertainty may be influenced by threat, fear/worry, and biased attending. Further studies are needed to develop and test psychosocial interventions to reduce fear and threat of pain in youth with IBD in partnership with families and providers.

Mind-body-medicine and comprehensive lifestyle-modification in patients with Crohn's disease—Feasibility of a randomized controlled trial under pandemic circumstances

Introduction

Mind-body medicine (MBM) focuses on stress reduction and lifestyle changes. The primary objective of this pilot trial was to test study feasibility of a complex integrative MBM program for patients with Crohn's disease (CD), especially in rural regions, and under pandemic conditions.

Methods

Patients were stratified and randomized to the intervention group (IG) or the control group (CG). The intervention included a weekly 6-h session for 10 weeks. The CG (waiting list) received an initial 90-min workshop and started the intervention 9 months later. The primary outcome for study feasibility was recruitment and retention rates, as well as reasons for drop-out. The trial took place in Bamberg, Germany (September 2020 to December 2021).

Results

Totally 700 members of the German Crohn's and Colitis Organization—DCCV—were contacted. A total of 15% (102/700; 95% CI 12–17%) expressed interest to participate. Following screening, 41% (95% CI 32–50) were randomized to IG (n = 22) and CG (n = 20). The patients were on average (±standard deviation) 48 ± 13 years old, 67% were female, and have been suffering from CD for 20 ± 12 years. Patients traveled 71.5 ± 48.7 km (range: 9–227 km) to the intervention with no differences between IG and CG. At the 6-month follow-up, 36/42 (86%, 95% CI 74–95%) participants completed final assessment and 19/22 (86%, 95% CI 70–100%) the intervention. The most important reasons for non-responding were work-related (12/60; 20%) and for or drop-out pandemic-related anxiety (3/6). No patient and staff member became infected with SARS-CoV-2 during the study.

Conclusion

The feasibility of the MBM study was confirmed in terms of predefined recruitment and retention criteria, both despite difficult conditions (including the rural setting) and patients' fears associated with the pandemic. It was crucial to develop appropriate hygiene and safety concepts that enable chronically ill patients to participate in helpful group-based interventions even under pandemic conditions.

Clinical trial registration

ClinicalTrials.gov, identifier: NCT05182645.

Abdominal Pain in Inflammatory Bowel Diseases: A Clinical Challenge

Up to 60% of inflammatory bowel disease (IBD) patients experience abdominal pain in their lifetime regardless of disease activity. Pain negatively affects different areas of daily life and particularly impacts the quality of life of IBD patients. This review provides a comprehensive overview of the multifactorial etiology implicated in the chronic abdominal pain of IBD patients including peripheral sensitization by inflammation, coexistent irritable bowel syndrome, visceral hypersensitivity, alteration of the brain-gut axis, and the multiple factors contributing to pain persistence. Despite the optimal management of intestinal inflammation, chronic abdominal pain can persist, and pharmacological and non-pharmacological approaches are necessary. Integrating psychological support in care models in IBD could decrease disease burden and health care costs. Consequently, a multidisciplinary approach similar to that used for other chronic pain conditions should be recommended.

The Effect of Serine Protease Inhibitors on Visceral Pain in Different Rodent Models With an Intestinal Insult

Background: Serine proteases are believed to play a key role in the origin of abdominal pain in IBD and IBS. We previously demonstrated a reduction of visceral pain in a post-inflammatory IBS rat model after a single intraperitoneal or intracolonic administration of a serine protease inhibitor. The aim of this study was to investigate the efficacy of serine protease inhibition on visceral pain in two different animal models involving a colonic insult based either on acute inflammation or on neonatal irritation. Moreover, protease profiling was explored in the acute colitis model. Methods: An acute 2,4,6-trinitrobenzenesulphonic acid (TNBS) colitis rat model and a chronic neonatal acetic acid mouse model were used in this study. Visceral sensitivity was quantified by visceromotor responses (VMRs) to colorectal distension, 30 min after intraperitoneal administration of the serine protease inhibitors nafamostat, UAMC-00050 or their vehicles. Colonic samples from acute colitis rats were used to quantify the mRNA expression of a panel of serine proteases and mast cell tryptase by immunohistochemistry. Finally, proteolytic activities in colonic and fecal samples were characterized using fluorogenic substrates. Key Results: We showed a significant and pressure-dependent increase in visceral hypersensitivity in acute colitis and neonatal acetic acid models. UAMC-00050 and nafamostat significantly reduced VMRs in both animal models. In acute colitis rats, the administration of a serine protease inhibitor did not affect the inflammatory parameters. Protease profiling of these acute colitis animals revealed an increased tryptase immunoreactivity and a downregulation of matriptase at the mRNA level after inflammation. The administration of UAMC-00050 resulted in a decreased elastase-like activity in the colon associated with a significantly increased elastase-like activity in fecal samples of acute colitis animals. Conclusion: In conclusion, our results suggest that serine proteases play an important role in visceral hypersensitivity in an acute TNBS colitis model in rats and a neonatal acetic acid model in mice. Moreover, we hypothesize a potential mechanism of action of UAMC-00050 via the alteration of elastase-like proteolytic activity in acute inflammation. Taken together, we provided fundamental evidence for serine protease inhibitors as a promising new therapeutic strategy for abdominal pain in gastrointestinal diseases.

A Novel Digital Self-management Intervention for Symptoms of Fatigue, Pain, and Urgency in Inflammatory Bowel Disease: Describing the Process of Development

Background

Empirical studies and systematic reviews have demonstrated the role of biological, cognitive, behavioral, and emotional factors in fatigue, pain, and urgency in inflammatory bowel disease (IBD). Behavioral management that addresses the cognitive, behavioral, and emotional factors offered alongside medical treatment is seldom available to people with IBD. Digital interventions provide a potentially scalable and cost-effective way of providing behavioral support to patients.

Objective

This paper aimed to describe the process of developing a supported digital self-management intervention for fatigue, pain, and urgency in IBD using theory and evidence-based approaches and stakeholder input.

Methods

The Medical Research Council framework for complex health interventions and a person-based approach were used to guide intervention development, consulting with 87 patients with IBD and 60 nurses. These frameworks informed the selection and use of a theoretical model that subsequently guided cognitive behaviorally based intervention content. They also guided the design of tailored digital intervention pathways for individuals with IBD that matched the predominant symptoms.

Results

A transsymptomatic cognitive behavioral framework of symptom perpetuation was developed for the symptoms of fatigue, pain, and urgency in IBD. A logic model was used to define the intervention techniques. Patient feedback and qualitative interviews refined the website content and functionalities, including the use of visual aids, email reminders, and graphical tracking of symptoms. Nurse focus groups informed the volume and delivery model of the therapist facilitator support. Ratings of acceptability out of 10 following feasibility testing (31/87, 36%) demonstrated accessibility (scoring 9.43, SD 1.040), ease (scoring 8.07, SD 3.205), clarity, and the relevant tone of the intervention. The final intervention comprised 12 web-based sessions (8 core and 4 symptom-specific), with one 30-minute facilitator phone call following session 1 and subsequent on-site messaging.

Conclusions

The use of theory and integration of stakeholders’ views throughout informed the development of an evidence-based digital intervention for fatigue, pain, and urgency in IBD. This is the first web-based self-management intervention designed to address these multiple symptoms with the aim of improving the quality of life and reducing the symptom burden of IBD. The intervention is being tested in a large multicenter randomized controlled trial.

Trial Registration

ISRCTN Registry ISRCTN71618461; https://www.isrctn.com/ISRCTN71618461

Reducing Pain in Experimental Models of Intestinal Inflammation Affects the Immune Response

The incidence of inflammatory bowel disease with its two main manifestations, colitis ulcerosa and Crohn's disease, is rising globally year after year. There is still a tremendous need to study the underlying pathomechanisms and a well-established tool in order to better understand the disease are colitis models in rodents. Since the concept of the 3Rs was proposed by Russell and Burch, this would include pain medication in animal models of intestinal inflammation as a reduction of suffering. This review argues against pain medication because the administration of pain medication in its current form has an impact on the inflammatory process and the immune response, thus falsifying the results and the reproducibility and therefore leading to misconceptions.

Prevalence and impact of Rome IV versus Rome III irritable bowel syndrome in patients with inflammatory bowel disease

BACKGROUND

Irritable bowel syndrome (IBS)-type symptoms are common in inflammatory bowel disease (IBD), but few studies have examined the prevalence and impact of IBS-type symptoms in IBD according to Rome IV criteria.

METHODS

We collected demographic, symptom (Rome III, Rome IV, and clinical disease activity indices), psychological (anxiety, depression, and somatization), and quality of life data from 973 IBD patients. Medical records were reviewed to document disease type, extent/location, behavior, medical therapy, and antidepressant or opioid use. We compared characteristics of individuals with no IBS-type symptoms, Rome III IBS-type symptoms, and Rome IV IBS-type symptoms.

KEY RESULTS

In total, 302 (31.0%) patients met the Rome III criteria for IBS, and 172 (17.7%) met Rome IV criteria. Those with IBS-type symptoms were younger, more likely to be female, and had higher rates of antidepressant (p = 0.006) or opioid use (p = 0.001). Rome IV IBS-type symptoms were associated with symptoms of mood disorders, flare of disease activity, and lower quality of life scores (p < 0.001 for all analyses). Compared with Rome III criteria, those with Rome IV IBS-type symptoms had significantly higher rates of anxiety (p < 0.001), depression (p = 0.002), and somatization (p < 0.001), lower quality of life scores (p < 0.001) and were more likely to have CD (p = 0.011), with ileal distribution (p = 0.006).

CONCLUSIONS AND INFERENCES

Rome IV IBS-type symptoms are associated with increased psychological co-morbidity, lower quality of life scores, and higher rates of antidepressant or opioid use. This is a cohort potentially at risk of adverse clinical outcomes and should be a focus for future research.

Perspectives of East Asian patients and physicians on complementary and alternative medicine use for inflammatory bowel disease: results of a cross-sectional, multinational study

Background/Aims

Complementary and alternative medicine (CAM) is prevalent in East Asia. However, information on CAM in East Asian patients with inflammatory bowel disease (IBD) is scarce. We aimed to profile the prevalence and pattern of CAM use among East Asian IBD patients and to identify factors associated with CAM use. We also compared physicians’ perspectives on CAM.

Methods

Patients with IBD from China, Japan, and South Korea were invited to complete questionnaires on CAM use. Patient demographic and clinical data were collected. Logistic regression analysis was applied for predictors of CAM use. Physicians from each country were asked about their opinion on CAM services or products.

Results

Overall, 905 patients with IBD participated in this study (China 232, Japan 255, and South Korea 418). Approximately 8.6% of patients with IBD used CAM services for their disease, while 29.7% of patients sought at least 1 kind of CAM product. Current active disease and Chinese or South Korean nationality over Japanese were independent predictors of CAM use. Chinese doctors were more likely to consider CAM helpful for patients with IBD than were Japanese and South Korean doctors.

Conclusions

In 8.6% and 29.7% of East Asian patients with IBD used CAM services and products, respectively, which does not differ from the prevalence in their Western counterparts. There is a significant gap regarding CAM usage among different Asian countries, not only from the patients’ perspective but also from the physicians’ point of view.

Recruitment of α4β7 monocytes and neutrophils to the brain in experimental colitis is associated with elevated cytokines and anxiety-like behavior

Background

Behavioral comorbidities, such as anxiety and depression, are a prominent feature of IBD. The signals from the inflamed gut that cause changes in the brain leading to these behavioral comorbidities remain to be fully elucidated. We tested the hypothesis that enhanced leukocyte–cerebral endothelial cell interactions occur in the brain in experimental colitis, mediated by α4β7 integrin, to initiate neuroimmune activation and anxiety-like behavior.

Methods

Female mice treated with dextran sodium sulfate were studied at the peak of acute colitis. Circulating leukocyte populations were determined using flow cytometry. Leukocyte–cerebral endothelial cell interactions were examined using intravital microscopy in mice treated with anti-integrin antibodies. Brain cytokine and chemokines were assessed using a multiplex assay in animals treated with anti-α4β7 integrin. Anxiety-like behavior was assessed using an elevated plus maze in animals after treatment with an intracerebroventricular injection of interleukin 1 receptor antagonist.

Results

The proportion of classical monocytes expressing α4β7 integrin was increased in peripheral blood of mice with colitis. An increase in the number of rolling and adherent leukocytes on cerebral endothelial cells was observed, the majority of which were neutrophils. Treatment with anti-α4β7 integrin significantly reduced the number of rolling leukocytes. After anti-Ly6C treatment to deplete monocytes, the number of rolling and adhering neutrophils was significantly reduced in mice with colitis. Interleukin-1β and CCL2 levels were elevated in the brain and treatment with anti-α4β7 significantly reduced them. Enhanced anxiety-like behavior in mice with colitis was reversed by treatment with interleukin 1 receptor antagonist.

Conclusions

In experimental colitis, α4β7 integrin-expressing monocytes direct the recruitment of neutrophils to the cerebral vasculature, leading to elevated cytokine levels. Increased interleukin-1β mediates anxiety-like behavior.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12974-022-02431-z.

Systematic Review and Meta-analysis on the Incidence, Prevalence and Determinants of Discomfort in Inflammatory Bowel Disease

Background

The symptom burden in inflammatory bowel disease (IBD) has a significant negative impact on the health-related quality of life (HRQOL). Patients with IBD report physical, psychological and social discomfort even during remission.

Aim

To synthesize the best available evidence to determine the worldwide incidence, prevalence and determinants of discomfort in adults with inflammatory bowel disease (IBD).

Methods

Following PRISMA recommendations, we searched the Medline, CINAHL, PsycInfo, Embase, Cochrane, Campbell and JBI Evidence Synthesis databases for studies on either incidence or prevalence of discomfort in English until January 2021. Data were extracted using the Joanna Briggs Institute's standardized extraction tools. Data that directly reported or could be used to calculate the incidence and prevalence of discomfort were extracted. Ten studies were eligible for inclusion in this review. Overall, the methodological quality of the included studies was considered moderate. Data measuring the incidence of discomfort in 6 out of 10 identified studies using the same measurement tool (EQ-5D) were pooled in a meta-analysis. Additional results have been presented in a narrative form, including tables.

Results

There is no standardized definition or tool utilized to describe or measure discomfort in IBD. Synthesized findings demonstrate that discomfort is prevalent among adults living with IBD. Determinants of discomfort included health literacy, disease activity, hospitalization/surgery, age and gender, delayed diagnosis, local practice standards and quality of IBD care.

Conclusions

More research is needed to identify the impact of discomfort on health-related outcomes for people with IBD and consequently appraise discomfort interventions for their efficacy.

How Should Pain, Fatigue, and Emotional Wellness Be Incorporated Into Treatment Goals for Optimal Management of Inflammatory Bowel Disease?

Early diagnosis and the optimal control of inflammation, with a continuous cycle of assessment, treatment, monitoring, and adjustment of therapy, is best practice for the management of inflammatory bowel disease. However, patients express frustration with ongoing challenging symptoms, often discordant with inflammation, including abdominal pain, fatigue, depression, anxiety, and emotional wellness; these are often not optimally addressed by inflammatory bowel disease clinicians due to lack of time or resources. This review will highlight the burden of these symptoms and issues, suggest ways of assessing these in clinical practice, highlight the importance of acknowledging and validating the symptoms and issues with patients, reassuring them that they are being heard, and discuss different possible models of service delivery for psychosocial support, from fully integrated gastropsychology models to referral pathways that optimize community support. We suggest the importance of the treat-to-target concept, where the target is not only control of inflammation but also emotional wellness.

Chronic pain and infection: mechanisms, causes, conditions, treatments, and controversies

Throughout human history, infection has been the leading cause of morbidity and mortality, with pain being one of the cardinal warning signs. However, in a substantial percentage of cases, pain can persist after resolution of acute illness, manifesting as neuropathic, nociplastic (eg, fibromyalgia, irritable bowel syndrome), or nociceptive pain. Mechanisms by which acute infectious pain becomes chronic are variable and can include immunological phenomena (eg, bystander activation, molecular mimicry), direct microbe invasion, central sensitization from physical or psychological triggers, and complications from treatment. Microbes resulting in a high incidence of chronic pain include bacteria such as the Borrelia species and Mycobacterium leprae, as well as viruses such as HIV, SARS-CoV-2 and herpeses. Emerging evidence also supports an infectious cause in a subset of patients with discogenic low back pain and inflammatory bowel disease. Although antimicrobial treatment might have a role in treating chronic pain states that involve active infectious inflammatory processes, their use in chronic pain conditions resulting from autoimmune mechanisms, central sensitization and irrevocable tissue (eg, arthropathy, vasculitis) or nerve injury, are likely to cause more harm than benefit. This review focuses on the relation between infection and chronic pain, with an emphasis on common viral and bacterial causes.

Gut-innervating TRPV1+ Neurons Drive Chronic Visceral Pain via Microglial P2Y12 Receptor

BACKGROUND & AIMS

Chronic abdominal pain is a common symptom of inflammatory bowel diseases (IBDs). Peripheral and central mechanisms contribute to the transition from acute to chronic pain during active disease and clinical remission. Lower mechanical threshold and hyperexcitability of visceral afferents induce gliosis in central pain circuits, leading to persistent visceral hypersensitivity (VHS). In the spinal cord, microglia, the immune sentinels of the central nervous system, undergo activation in multiple models of VHS. Here, we investigated the mechanisms of microglia activation to identify centrally acting analgesics for chronic IBD pain.

METHODS

Using Designer Receptors Exclusively Activated by Designer Drugs (DREADD) expressed in transient receptor potential vanilloid member 1-expressing visceral neurons that sense colonic inflammation, we tested whether neuronal activity was indispensable to control microglia activation and VHS. We then investigated the neuron-microglia signaling system involved in visceral pain chronification.

RESULTS

We found that chemogenetic inhibition of transient receptor potential vanilloid member 1⁺ visceral afferents prevents microglial activation in the spinal cord and subsequent VHS in colitis mice. In contrast, chemogenetic activation, in the absence of colitis, enhanced microglial activation associated with VHS. We identified a purinergic signaling mechanism mediated by neuronal adenosine triphosphate (ATP) and microglial P2Y12 receptor, triggering VHS in colitis. Inhibition of P2RY12 prevented microglial reactivity and chronic VHS post-colitis.

CONCLUSIONS

Overall, these data provide novel insights into the central mechanisms of chronic visceral pain and suggest that targeting microglial P2RY12 signaling could be harnessed to relieve pain in patients with IBD who are in remission.

Interventions for the management of abdominal pain in Crohn's disease and inflammatory bowel disease

BACKGROUND

Crohn's disease is a remitting and relapsing disorder that can affect the whole gastrointestinal tract. Active disease symptoms include abdominal pain, fatigue, weight loss, and diarrhoea. There is no known cure; however, the disease can be managed, and therefore places a huge financial burden on healthcare systems. Abdominal pain is a common and debilitating symptom of Crohn's and other inflammatory bowel diseases (IBDs), and is multifaceted. Abdominal pain in Crohn's disease could be a symptom of disease relapse or related to medication adverse effects, surgical complications and strictures or adhesions secondary to IBD. In the absence of these factors, around 20 to 50% of people with Crohn's in remission still experience pain.

OBJECTIVES

To assess the efficacy and safety of interventions for managing abdominal pain in people with Crohn's disease and IBD (where data on ulcerative colitis and Crohn's disease could not be separated).

SEARCH METHODS

We searched CENTRAL, MEDLINE, three other databases, and clinical trials registries on 29 April 2021. We also searched the references of trials and systematic reviews for any additional trials.

SELECTION CRITERIA

All published, unpublished, and ongoing randomised trials that compared interventions for the management of abdominal pain in the setting of Crohn's disease and IBD, with other active interventions or standard therapy, placebo, or no therapy were included. We excluded studies that did not report on any abdominal pain outcomes.

DATA COLLECTION AND ANALYSIS

Five review authors independently conducted data extraction and 'Risk of bias' assessment of the included studies. We analysed data using Review Manager 5. We expressed dichotomous and continuous outcomes as risk ratios and mean differences with 95% confidence intervals. We assessed the certainty of the evidence using GRADE methodology.

MAIN RESULTS

We included 14 studies (743 randomised participants). Five studies evaluated participants with Crohn's disease; seven studies evaluated participants with IBD where the data on ulcerative colitis and Crohn's disease could not be separated; and two studies provided separate results for Crohn's disease participants. Studies considered a range of disease activity states. Two studies provided intervention success definitions, whilst the remaining studies measured pain as a continuous outcome on a rating scale. All studies except one measured pain intensity, whilst three studies measured pain frequency. Withdrawals due to adverse events were directly or indirectly reported in 10 studies. No conclusions could be drawn about the efficacy of the majority of the interventions on pain intensity, pain frequency, and treatment success, except for the comparison of transcranial direct current stimulation to sham stimulation. The certainty of the evidence was very low in all but one comparison because of imprecision due to sparse data and risk of bias assessed as unclear or high risk. Two studies compared a low FODMAP diet (n=37) to a sham diet (n=45) in IBD patients. The evidence on pain intensity was of very low certainty (MD -12.00, 95% CI -114.55 to 90.55). One study reported pain intensity separately for CD participants in the low FODMAP group [n=14, mean(SD)=24 (82.3)] and the sham group [n=12, mean(SD)=32 (69.3)]. The same study also reported pain frequency for IBD participants in the low FODMAP group [n=27, mean(SD)=36 (26)] and sham group [n=25, mean(SD)=38(25)] and CD participants in the low FODMAP group [n=14, mean(SD)=36 (138.4)] and sham group [n=12, mean(SD)=48 (128.2)]. Treatment success was not reported. One study compared a low FODMAP diet (n=25) to high FODMAP/normal diet (n=25) in IBD patients. The data reported on pain intensity was unclear. Treatment success and pain frequency were not reported. One study compared medicine-separated moxibustion combined with acupuncture (n=51) versus wheat bran-separated moxibustion combined with shallow acupuncture (n=51) in CD patients. The data reported on pain intensity and frequency were unclear. Treatment success was not reported. One study compared mindfulness with CBT (n=33) versus no treatment (n=33) in IBD patients. The evidence is very uncertain about the effect of this treatment on pain intensity and frequency (MD -37.00, 95% CI -87.29 to 13.29). Treatment success was not reported. One study compared soft non-manipulative osteopathic treatment (n=16) with no treatment besides doctor advice (n=14) in CD patients. The evidence is very uncertain about the effect of this treatment on pain intensity (MD 0.01, 95% CI -1.81 to 1.83). Treatment success and pain frequency were not reported. One study compared stress management (n=15) to self-directed stress management(n=15) and to standard treatment (n=15) in CD patients. The evidence is very uncertain about the effect of these treatments on pain intensity (MD -30.50, 95% CI -58.45 to -2.55 and MD -34.30, 95% CI -61.99 to -6.61). Treatment success and pain frequency were not reported. One study compared enteric-release glyceryl trinitrate (n=34) with placebo (n=36) in CD patients. The data reported on pain intensity was unclear. Treatment success and pain frequency were not reported.  One study compared 100 mg olorinab three times per day (n=8) with 25 mg olorinab three times per day (n=6) in CD patients. Pain intensity was measured as a 30% reduction in weekly average abdominal pain intensity score for the 100mg group (n=5) and the 25mg group (n=6). The evidence is very uncertain about the effect of this treatment on pain intensity (RR 0.66, 95% CI 0.38 to 1.15). Treatment success and pain frequency were not reported. One study compared relaxation training (n=28) to a waitlist (n=28) in IBD patients. The evidence is very uncertain about the effect of this treatment on pain intensity (MD -0.72, 95% CI -1.85 to 0.41). Treatment success and pain frequency were not reported. One study compared web-based education (n=30) with a book-based education (n=30) in IBD patients. The evidence is very uncertain about the effect of this treatment on pain intensity (MD -0.13, 95% CI -1.25 to 0.99). Treatment success and pain frequency were not reported. One study compared yoga (n=50) with no treatment (n=50) in IBD patients. The data reported on treatment success were unclear. Pain frequency and intensity were not reported. One study compared transcranial direct current stimulation (n = 10) to sham stimulation (n = 10) in IBD patients. There may be an improvement in pain intensity when transcranial direct current is compared to sham stimulation (MD -1.65, 95% CI -3.29 to -0.01, low-certainty evidence). Treatment success and pain frequency were not reported. One study compared a kefir diet (Lactobacillus bacteria) to no intervention in IBD patients and provided separate data for their CD participants. The evidence is very uncertain about the effect of this treatment on pain intensity in IBD (MD 0.62, 95% CI 0.17 to 1.07) and CD (MD -1.10, 95% CI -1.67 to -0.53). Treatment success and pain frequency were not reported. Reporting of our secondary outcomes was inconsistent. The most adverse events were reported in the enteric-release glyceryl trinitrate and olorinab studies.  In the enteric-release glyceryl trinitrate study, the adverse events were higher in the intervention arm. In the olorinab study, more adverse events were observed in the higher dose arm of the intervention.  In the studies on non-drug interventions, adverse events tended to be very low or zero. However, no clear judgements regarding adverse events can be drawn for any interventions due to the low number of events. Anxiety and depression were measured and reported at the end of intervention in only one study; therefore, no meaningful conclusions can be drawn for this outcome.

AUTHORS' CONCLUSIONS

We found low certainty evidence that transcranial direct current stimulation may improve pain intensity compared to sham stimulation. We could not reach any conclusions on the efficacy of any other interventions on pain intensity, pain frequency, and treatment success. The certainty of the evidence was very low due to the low numbers of studies and participants in each comparison and clinical heterogeneity amongst the studies. While no serious or total adverse events were elicited explicitly with any of the treatments studied, the reported events were very low. The certainty of the evidence for all comparisons was very low, so no conclusions can be drawn.

Patient Strategies for Managing the Vicious Cycle of Fatigue, Pain and Urgency in Inflammatory Bowel Disease: Impact, Planning and Support

BACKGROUND

Inflammatory bowel disease (IBD) causes inter-related symptoms of fatigue, pain and urgency which can persist in remission.

AIM

To understand how people with IBD experience and self-manage these symptoms and to inform the future development of an online self-management programme.

METHODS

Using exploratory qualitative methods, we recruited participants from clinic and community settings. Focus groups, conducted across the UK, were audio-recorded and professionally transcribed. Transcripts were analysed over four rounds using framework analysis. Eight patients were consulted to agree the final structure of data and themes.

RESULTS

Seven focus groups were held; five gave useable data. Twenty-six participants (15 female; ages 21-60 years; disease duration 2-40 years) with Crohn's disease (n = 10), ulcerative colitis (n = 14) and IBD-unclassified (n = 2) attended one of these five focus groups. Three core themes emerged: The Negative Impact of Symptoms, Positively Taking Control and Seeking and Receiving Support. The persistent, often stark impact of multiple co-existing symptoms on physical and emotional wellbeing can force unwanted adjustments and limitations in working, social and intimate arenas of life. Unpredictable symptoms are challenging and impact each other in negative vicious cycles. Managing diet, pacing, accepting background levels of fatigue, pain and urgency, seeking support, exercising and attending to mental wellbeing, are all perceived as helpful in self-managing symptoms.

CONCLUSION

Fatigue, pain and urgency are troublesome for patients, especially in combination, suggesting that these should be addressed simultaneously by clinicians. Participants reported several strategies for self-management, providing patient-focused evidence to inform future development of a self-management intervention programme.

Post-inflammatory Abdominal Pain in Patients with Inflammatory Bowel Disease During Remission: A Comprehensive Review

Patients with inflammatory bowel disease often experience ongoing pain even after achieving mucosal healing (i.e., post-inflammatory pain). Factors related to the brain-gut axis, such as peripheral and central sensitization, altered sympatho-vagal balance, hypothalamic-pituitary-adrenal axis activation, and psychosocial factors, play a significant role in the development of post-inflammatory pain. A comprehensive study investigating the interaction between multiple predisposing factors, including clinical psycho-physiological phenotypes, molecular mechanisms, and multi-omics data, is still needed to fully understand the complex mechanism of post-inflammatory pain. Furthermore, current treatment options are limited and new treatments consistent with the underlying pathophysiology are needed to improve clinical outcomes.

Supported online self-management versus care as usual for symptoms of fatigue, pain and urgency/incontinence in adults with inflammatory bowel disease (IBD-BOOST): study protocol for a randomised controlled trial

BACKGROUND

Despite being in clinical remission, many people with inflammatory bowel disease (IBD) live with fatigue, chronic abdominal pain and bowel urgency or incontinence that limit their quality of life. We aim to test the effectiveness of an online self-management programme (BOOST), developed using cognitive behavioural principles and a theoretically informed logic model, and delivered with facilitator support.

PRIMARY RESEARCH QUESTION

In people with IBD who report symptoms of fatigue, pain or urgency and express a desire for intervention, does a facilitator-supported tailored (to patient needs) online self-management programme for fatigue, pain and faecal urgency/incontinence improve IBD-related quality of life (measured using the UK-IBDQ) and global rating of symptom relief (0-10 scale) compared with care as usual?

METHODS

A pragmatic two-arm, parallel group randomised controlled trial (RCT), of a 12-session facilitator-supported online cognitive behavioural self-management programme versus care as usual to manage symptoms of fatigue, pain and faecal urgency/incontinence in IBD. Patients will be recruited through a previous large-scale survey of unselected people with inflammatory bowel disease. The UK Inflammatory Bowel Disease Questionnaire and global rating of symptom relief at 6 months are the co-primary outcomes, with multiple secondary outcomes measured also at 6 and 12 months post randomisation to assess maintenance. The RCT has an embedded pilot study, health economics evaluation and process evaluation. We will randomise 680 patients, 340 in each group. Demographic characteristics and outcome measures will be presented for both study groups at baseline. The UK-IBDQ and global rating of symptom relief at 6 and 12 months post randomisation will be compared between the study groups.

DISCUSSION

The BOOST online self-management programme for people with IBD-related symptoms of fatigue, pain and urgency has been designed to be easily scalable and implemented. If it is shown to improve patients' quality of life, this trial will enable clinicians and patients to make informed management decisions. This is the first trial, to our knowledge, focused on multiple symptoms prioritised by both people with IBD and health professionals.

TRIAL REGISTRATION

ISRCTN71618461 . Registered on 9 September 2019.

Interventions for the management of abdominal pain in ulcerative colitis

BACKGROUND

Ulcerative colitis (UC) is a chronic inflammation of the colon characterised by periods of relapse and remission. It starts in the rectum and can extend throughout the colon. UC and Crohn's disease (CD) are the most common inflammatory bowel diseases (IBDs). However, UC tends to be more common than CD. It has no known cure but can be managed with medication and surgery. However, studies have shown that abdominal pain persists in up to one-third of people with UC in remission. Abdominal pain could be a symptom of relapse of the disease due to adverse effects of medication, surgical complications and strictures or adhesions secondary to UC.

OBJECTIVES

To assess the efficacy and safety of interventions for managing abdominal pain in people with ulcerative colitis.

SEARCH METHODS

We searched CENTRAL, MEDLINE and five other databases and clinical trials registries on 28 April 2021. We contacted authors of relevant studies and ongoing or unpublished trials that may be relevant to the review. We also searched references of trials and systematic reviews for any additional trials.

SELECTION CRITERIA

All published, unpublished and ongoing randomised trials that compared interventions for the management of abdominal pain with other active interventions or standard therapy, placebo or no therapy were included. People with both active and inactive disease were included. We excluded studies that did not report on any abdominal pain outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted data extraction and 'Risk of bias' assessments. We analysed data using Review Manager 5. We expressed dichotomous and continuous outcomes as risk ratios (RRs) and mean differences (MDs), respectively, with 95% confidence intervals. We assessed the certainty of the evidence using the GRADE methodology.

MAIN RESULTS

We included five studies (360 randomised participants). Studies considered mainly participants in an inactive state of the disease.   No conclusions could be drawn about the efficacy of any of the interventions on pain frequency, pain intensity, and treatment success. The certainty of the evidence was very low for all comparisons because of imprecision due to sparse data, and risk of bias. One study compared a low FODMAPs diet (n=13) to a sham diet (n=13). The evidence is very uncertain about the effect of this treatment on pain frequency (MD -4.00, 95% CI -20.61 to 12.61) and intensity (MD -9.00, 95% CI -20.07 to 2.07). Treatment success was not reported. One study compared relaxation training (n=20) to wait-list (n=20). The evidence is very uncertain about the effect of this treatment on pain frequency at end of intervention (MD 2.60, 95% CI 1.14 to 4.06) and 6-month follow-up (MD 3.30, 95% CI 1.64 to 4.96). Similarly, the evidence is very uncertain about the effect of this treatment on pain intensity at end of intervention (MD -1.70, 95% CI -2.92 to -0.48) and 6-month follow-up (MD -2.30, 95% CI -3.70 to -0.90). Treatment success was not reported. One study compared yoga (n=30) to no intervention (n=30). The study defined treatment success as the presence or absence of pain; however, the data they provided was unclear. Pain frequency and intensity were not reported. One study compared a kefir diet (Lactobacillus bacteria, n=15) to no intervention (n=15). The evidence is very uncertain about the effect of this treatment on pain intensity (MD -0.17, 95% CI -0.91 to 0.57). Pain frequency and treatment success were not reported. One study compared a stellate ganglion block treatment (n=90) to sulfasalazine treatment (n=30). The study defined treatment success as "stomachache"; however, the data they provided was unclear. Pain frequency and intensity were not reported. Two studies reported withdrawals due to adverse events. One study reported withdrawals due to adverse events as zero. Two studies did not report this outcome.  We cannot draw any conclusions about the effects of any of the interventions on withdrawals due to adverse events because of the very limited evidence. The reporting of secondary outcomes was inconsistent. Adverse events tended to be very low or zero. However, we can make no clear judgements about adverse events for any of the interventions, due to the low number of events. Anxiety was measured and reported at end of intervention in only one study (yoga versus no intervention), and depression was not measured in any of the studies. We can therefore draw no meaningful conclusions about these outcomes.

AUTHORS' CONCLUSIONS

We found very low-certainty evidence on the efficacy and safety of interventions for the management of abdominal pain in ulcerative colitis. Pervasive issues with very serious imprecision from small samples size and high risk of bias have led to very low-certainty outcomes, precluding conclusions. While few adverse events and no serious adverse events were reported, the certainty of these findings was again very low for all comparisons, so no conclusions can be drawn. There is a need for further research. We have identified eight ongoing studies in this review, so an update will be warranted. It is key that future research addresses the issues leading to reduced certainty of outcomes, specifically sample size and reporting that leads to high risk of bias. It is also important that if researchers are considering pain as a critical outcome, they should report clearly if participants were pain-free at baseline; in that case, data would be best presented as separate subgroups throughout their research.

Xi Lei San Attenuates Dextran Sulfate Sodium-Induced Colitis in Rats and TNF-α-Stimulated Colitis in CACO2 Cells: Involvement of the NLRP3 Inflammasome and Autophagy

Objective

Inflammatory bowel disease (IBD) is a chronic nonspecific inflammatory bowel disease with an unclear etiology. The active ingredients of traditional Chinese medicines (TCMs) exert anti-inflammatory, antitumor, and immunomodulatory effects, and their multitarget characteristics provide them with a unique advantage for treating IBD. However, the therapeutic effects and underlying mechanisms of Xi Lei San in treatment of IBD remain unknown. This study was designed to investigate whether Xi Lei San exerted an anti-inflammatory effect in IBD via a mechanism involving NLRP3 inflammasomes and autophagy.

Methods

We successfully established a rat model of dextran sulfate sodium- (DSS-) induced colitis as well as a cellular model of TNF-α-induced colitis. Xi Lei San and indirubin were identified by HPLC analysis. Rats were treated with Xi Lei San or alum crystals, and their body weights and morphology of intestinal tissues were examined. A western blot analysis was performed to determine the expression levels of inflammasome-related proteins and autophagy-related proteins, ELISA was performed to analyze IL-1β, IL-18, and IL-33 concentrations, and flow cytometry was used to monitor cell apoptosis and ROS levels.

Results

Xi Lei San and indirubin were identified by HPLC analysis. We found that Xi Lei San could significantly increase the weights of rats and improve the structure of the intestinal tissues in DSS-induced colitis model rats. We also found that Xi Lei San significantly inhibited NLRP3 inflammasome activity, reduced the levels of inflammatory cytokines, and suppressed autophagy in DSS-induced colitis model rats. In vitro experiments revealed that Xi Lei San could repress apoptosis as well as ROS and inflammatory cytokine production in TNF-α-induced CACO2 cells by reducing the activity of NLRP3 inflammasomes and autophagy.

Conclusions

Our findings showed that Xi Lei San significantly ameliorated IBD by inhibiting NLRP3 inflammasome, autophagy, and oxidative stress.

Trends in US emergency department visits and subsequent hospital admission among patients with inflammatory bowel disease presenting with abdominal pain: a real-world study from a national emergency department sample database

Background/Objective: This study evaluated emergency department (ED) visit trends, subsequent inpatient admissions for patients with inflammatory bowel disease (IBD) diagnosis and IBD-related abdominal pain (AP), and hospital-level variation in inpatient admission rates in the USA (US). Methods: This population-based, cross-sectional study included data from Nationwide Emergency Department Sample (NEDS, 2006─2013) database. Patients ≥18 years of age with primary ED diagnosis of IBD/IBD-related AP were included. Variables included demographics, insurance information, household income, Quan-Charlson comorbidity score, ED discharge disposition, and length of hospital stay (2006, 2010, and 2013). Variation between hospitals using risk-adjusted admission ratio was estimated. Results: Annual ED visits for IBD/100,000 US population increased (30 in 2006 vs 42 in 2013, p = 0.09), subsequent admissions remained stable (20 in 2006 vs 23 in 2013, p = 0.52). ED visits for IBD-related AP increased by 71% (7 in 2006 vs 12 in 2013; p = 0.12), subsequent admissions were stable (0.50 in 2006 vs 0.58 in 2013; p = 0.88). Proportion of patients with subsequent hospitalization decreased (IBD: 65.7% to 55.7%; IBD-related AP: 6.9% to 4.9%). Variation in subsequent inpatient admissions was 1.42 (IBD) and 1.96 (IBD-related AP). Conclusions: An increase in annual ED visits was observed for patients with IBD and IBD-related AP; however, subsequent inpatient admission rate remained stable.

Pain management in inflammatory bowel disease: feasibility of an online therapist-supported CBT-based self-management intervention

BACKGROUND

Chronic pain is a poorly managed symptom of inflammatory bowel disease (IBD). Cognitive behavioural therapy (CBT) has an evidence base in functional gastrointestinal conditions and chronic pain. This study aimed to test the feasibility and acceptability of a 9-week online facilitator-supported CBT intervention, tailored for people with chronic IBD-related pain.

DESIGN

A single-arm pre-post design with nested qualitative interviews was used. Twenty individuals with IBD and chronic pain were recruited through an online IBD charity and had consented to research in a previous survey or responded to an online charity advert. Individuals who indicated a pain-interference score of ≥ 4/10 (Brief Pain Inventory) and met inclusion criteria were invited to take part. Outcomes included recruitment and retention rates, pain interference and severity, quality of life (QoL) and psychosocial measures.

RESULTS

Of 145 individuals contacted, 55 (37.9%) responded. Two individuals were recruited from the study advertisement. Twenty out of 57 (35.1%) met screening and eligibility criteria. Eighty-five percent of the sample engaged with intervention sessions and 55% completed at least 5/9 sessions. Eighty percent of recruited participants completed the post-intervention questionnaire at week 9. The mean score for overall acceptability was 43.4 (0-70). Qualitative feedback demonstrated the value of thought monitoring and facilitator support. Scores improved for QoL and pain self-efficacy and reduced for depression, anxiety, pain catastrophising and avoidance resting behaviour.

CONCLUSIONS

Online CBT for chronic IBD-related pain appears feasible and acceptable. The study suggests positive effects for improving QoL and reducing psychological distress; however, online and face-to-face recruitment methods are recommended and establishing efficacy through larger randomised controlled trials is required.

Systematic Review: Psychosocial Correlates of Pain in Pediatric Inflammatory Bowel Disease

BACKGROUND

Pain is a common symptom in pediatric inflammatory bowel disease (IBD) and is associated with poor health outcomes, yet additional knowledge about the psychosocial correlates of pain is needed to optimize clinical care. The purpose of this study is to systematically review the psychosocial factors associated with pain and pain impact in youth diagnosed with IBD within a developmentally informed framework.

METHODS

Manual and electronic searches yielded 2641 references. Two authors conducted screening (98% agreement), and data extraction was performed in duplicate. Average study quality was rated using the National Institutes of Health Quality Assessment Tool.

RESULTS

Ten studies (N = 763 patients; N = 563 Crohn disease, N = 200 ulcerative/ indeterminate colitis) met the inclusion criteria. Findings showed consistent evidence that higher levels of child depression symptoms and child pain catastrophizing were associated with significantly greater pain and pain impact (magnitude of association ranged from small to large across studies). Greater pain and pain impact were also associated with higher levels of child anxiety symptoms, child pain threat, child pain worry, and parent pain catastrophizing. Within the included studies, female sex and disease severity were both significantly associated with pain and pain impact. Study quality was moderate on average.

CONCLUSIONS

There is evidence that child psychosocial factors are associated with pain and pain impact in pediatric IBD; more studies are needed to examine parent- and family-level psychosocial factors. Youth with IBD should be routinely screened for pain severity, pain impact, and psychosocial risk factors such as anxiety/depression.

Increasing Rates of Opioid Prescriptions for Gastrointestinal Diseases in the United States

INTRODUCTION

Pain control is an important management approach for many gastrointestinal conditions. Because of the ongoing opioid crisis, public health efforts have focused on limiting opioid prescriptions. This study examines national opioid prescribing patterns and factors associated with opioid prescriptions for gastrointestinal conditions.

METHODS

We conducted a repeated cross-sectional study using the National Ambulatory Medical Care Survey data from 2006 to 2016. The International Classification of Diseases codes were used to identify ambulatory visits with a primary gastrointestinal diagnosis. Data were weighted to calculate national estimates for opioid prescriptions for gastrointestinal disease. Joinpoint regression was used to analyze temporal trends. Multivariable logistic regression was used to examine factors associated with opioid prescriptions.

RESULTS

We analyzed 12,170 visits with a primary gastrointestinal diagnosis, representing 351 million visits. The opioid prescription rate for gastrointestinal visits was 10.1% (95% confidence interval [CI] 9.0%-11.2%). Opioid prescription rates for gastrointestinal disease increased by 0.5% per year from 2006 to 2016 (P = 0.04). Prescription rates were highest for chronic pancreatitis (25.1%) and chronic liver disease (13.9%) visits. Seventy-one percent of opioid prescriptions were continuations of an existing prescription. Patient characteristics associated with continued opioid prescriptions included rural location (adjusted odds ratio [aOR] 1.46; 95% CI 1.11-1.93), depression (aOR 1.83; 95% CI 1.33-2.53), and Medicaid insurance (aOR 1.57; 95% CI 1.15-2.13).

DISCUSSION

Opioid prescription rates for gastrointestinal disease visits increased from 2006 to 2016. Our findings suggest an inadequate response to the opioid epidemic by providers managing gastrointestinal conditions. Further clinical interventions are needed to limit opioid use for gastrointestinal disease.(Equation is included in full-text article.).

Efficacy of Acupuncture in the Treatment of Chronic Abdominal Pain

Context

Abdominal pain is a widespread complaint and is one of the common reasons leading patients to seek medical care, either in emergency situations or with their primary providers. While acute abdominal pain is a better defined, usually surgical condition, chronic abdominal pain requires longer, typically lifelong, therapy. Chronic abdominal pain may also present with acute flares and complications. Here we review seminal and novel evidence discussing the use of acupuncture in the treatment of abdominal pain, indications, and conditions that may benefit from this approach.

Evidence Acquisition

Chronic abdominal pain is a common complaint causing significant morbidity and disability and has a hefty price tag attached. Recent studies show it may be prevalent in as much as 25% of the adult population. It is defined as three episodes of severe abdominal pain over the course of three months. Chronic abdominal pain could be the result of chronicity of acute pain or of chronic pain syndromes, most commonly IBD syndromes and IBS. While a plethora of treatments exists for both conditions, these treatments usually fall short of complete symptom control, and there is a need for complementary measures to curb disability and increase the quality of life in these patients. Acupuncture is a form of integrative medicine that has long been used in Chinese and traditional medicine, based on the rebalancing of the patient’s Qi, or Ying/Yang balance. It has been shown to be effective in treating several other conditions, and novel evidence may expand its use into other fields as well. Clinical trials studying acupuncture in chronic pain conditions have been promising, and recent evidence supports the use of abdominal pain in chronic abdominal pain conditions as well. Though not curative, acupuncture is a complementary approach that helps reduce symptoms and improved quality of life.

Conclusions

Chronic abdominal pain is a widespread condition, mostly affected by the IBS and IBD spectrum. Etiologies are still being studied for these conditions, and while novel treatment approaches are absolute game changers for these patients, many continue to experience some level of symptoms and disability. Acupuncture may provide further alleviation of these symptoms in select patients, thus improving quality of life, reducing disability, and saving healthcare dollars. It is a largely safe and inexpensive method that may significantly contribute to the quality of life of selected patients.

Determinants of quality of life and psychosocial adjustment to pediatric inflammatory bowel disease: A systematic review focused on Crohn's disease

BACKGROUND

Crohn's disease is a chronic and unpredictable inflammatory bowel disease that leads to important psychosocial difficulties especially during sensitive developmental stages such as childhood and adolescence. While risk factors for mood disorders have been identified in the literature, those for quality of life and psychosocial functioning have not.

OBJECTIVE

This systematic review explored the determinants of quality of life and psychosocial adjustment to pediatric Crohn's disease.

METHOD

Four international databases were consulted in March 2020: PubMed, PsychInfo, PubPsych and Cochrane Library. A series of keywords were entered in each database to identify the most recent relevant studies.

RESULTS

One hundred and sixty-eight articles were identified, of which twenty-nine met the inclusion criteria. The majority explored the determinants of quality of life, depression and anxiety, with a few focusing on psychosocial functioning. Consistently with the literature on psychological morbidity, disease activity and parental stress were also strong predictors of quality of life and psychosocial functioning. New evidence showed that abdominal pain, negative illness perceptions and internalizing symptoms were also common predictors of these outcomes.

CONCLUSIONS

Some risk factors of quality of life, distress and psychosocial functioning are similar, which could indicate that some patients could be at risk of presenting an accumulation of difficulties adjusting to the disease. The identification of these risk factors is fundamental to propose appropriate interventions. Therapeutic education, therapies focused on pain management or on the parent-child relationship can be considered to allow a better adjustment or prevent difficulties.

Psychological Comorbidity and Intervention in Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is associated with significant psychological comorbidities, with associated impacts on patient quality of life, disease course, and health care costs. The present article reviews the latest evidence on the etiology of psychological comorbidities in IBD, with a focus on shared inflammatory pathways. The current state of practice in managing and understanding psychological comorbidities from the perspective of both gastroenterology practice and psychological treatment is reviewed, with a focus on evidence-based treatments shown to be effective in managing depression, anxiety, stress, and improving IBD-related health outcomes.

Neural control of gut homeostasis

The gut-brain axis is a coordinated communication system that not only maintains homeostasis, but significantly influences higher cognitive functions and emotions, as well as neurological and behavioral disorders. Among the large populations of sensory and motor neurons that innervate the gut, insights into the function of primary afferent nociceptors, whose cell bodies reside in the dorsal root ganglia and nodose ganglia, have revealed their multiple crosstalk with several cell types within the gut wall, including epithelial, vascular, and immune cells. These bidirectional communications have immunoregulatory functions, control host response to pathogens, and modulate sensations associated with gastrointestinal disorders, through activation of immune cells and glia in the peripheral and central nervous system, respectively. Here, we will review the cellular and neurochemical basis of these interactions at the periphery, in dorsal root ganglia, and in the spinal cord. We will discuss the research gaps that should be addressed to get a better understanding of the multifunctional role of sensory neurons in maintaining gut homeostasis and regulating visceral sensitivity.

Adjunctive Pharmacotherapy Use in Patients With Ileal Pouch-Anal Anastomosis (IPAA)

Background

This study evaluated the prevalence of adjunctive pharmacotherapies use among ileal pouch-anal anastomosis (IPAA) patients.

Methods

The IBD Partners database was queried to compare IPAA patients with and without pouch-related symptoms (PRS). Within the cohort of patients with PRS, patient reported outcomes were compared among opioid, nonsteroidal anti-inflammatory drug (NSAID), and probiotic users.

Results

There were no differences in patient reported outcomes based on NSAID or probiotic usage. Opioid users reported increased bowel frequency, urgency, poor general well-being, abdominal pain, and depression (P < 0.05 for all variables).

Conclusions

In IPAA patients with PRS, opioid use, but not NSAIDs or probiotics, was associated with a higher burden of PRS.

Opioid Analgesics Do Not Improve Abdominal Pain or Quality of Life in Crohn's Disease

BACKGROUND

Abdominal pain and opioid analgesic use are common in Crohn's disease (CD).

AIMS

We sought to identify factors associated with abdominal pain in CD and evaluate the impact of opioid analgesics on pain and quality-of-life scores in this setting.

METHODS

We performed a longitudinal cohort study using a prospective, consented IBD natural history registry from a single academic center between 2009 and 2013. Consecutive CD patients were followed for at least 1 year after an index visit. Data were abstracted regarding pain experience (from validated surveys), inflammatory activity (using endoscopic/histologic findings), laboratory studies, coexistent psychiatric disorders, medical therapy, opioid analgesic, and tobacco use.

RESULTS

Of 542 CD patients (56.6% women), 232 (42.8%) described abdominal pain. Individuals with pain were more likely to undergo surgery and were more frequently prescribed analgesics and/or antidepressants/anxiolytics. Elevated ESR (OR 1.79; 95%CI 1.11-2.87), coexistent anxiety/depression (OR 1.87; 95%CI 1.13-3.09), smoking (OR 2.08; 95%CI 1.27-3.40), and opioid use (OR 2.46; 95%CI 1.33-4.57) were independently associated with abdominal pain. Eighty patients (14.8%) were prescribed opioids, while 31 began taking them at or after the index visit. Patients started on opioids demonstrated no improvement in abdominal pain or quality-of-life scores on follow-up compared to patients not taking opioids.

CONCLUSIONS

Abdominal pain is common in CD and is associated with significant opioid analgesic utilization and increased incidence of anxiety/depression, smoking, and elevated inflammatory markers. Importantly, opioid use in CD was not associated with improvement in pain or quality-of-life scores. These findings reinforce the limitations of currently available analgesics in IBD and support exploration of alternative therapies.

Developing a better biopsychosocial understanding of pain in inflammatory bowel disease: a cross-sectional study

OBJECTIVE

Pain is frequently reported by patients with inflammatory bowel disease (IBD). Pain in IBD is not fully explained by disease activity or other clinical findings, and a recent systematic review suggested that psychosocial factors have an important role in IBD-pain. The aim of this study was to investigate psychosocial factors associated with pain in IBD.

METHODS

297 adults (>16 years) with IBD were recruited from outpatient clinics (n = 114) and online (n = 183). Participants completed validated questionnaires assessing pain and potential emotional, cognitive and behavioural correlates. Socio-demographic and clinical factors including disease activity were also recorded.

RESULTS

243 (81.8%) of participants reported pain. Of these 243, mean age was 36 years; 153 (63%) had Crohn's disease, 90 (37%) had ulcerative colitis, and 165 (67.9%) were female. 62.6% reported mild, 31.6% moderate and 5.8% severe pain. 40.3% of participants with pain met established criteria for chronic pain and 18.5% reported opioid use. Female gender, smoking, surgery and steroid use were associated with greater pain severity. Psychosocial factors associated with pain-related interference included depression, catastrophising, fear avoidance, lower self-efficacy and worse mental well-being. Regression models explained 45.6% of the variance in pain severity and 49.7% of pain interference. Psychosocial factors explained 9.5% and 24% of this variance respectively when controlling for demographic and clinical variables.

CONCLUSIONS

Pain in IBD is significantly associated with cognitive and behavioural factors as well as low mood. This study contributes to a biopsychosocial understanding of pain in IBD and identifies important targets for future interventions.