Pain Experience in Ulcerative Colitis Patients
Abdominal pain is common in UC, occurring in 50-70% of patients during active disease flares, while patients in remission typically experience minimal to no abdominal pain. 1
Pain During Active Disease (Flares)
During disease flares, the majority of UC patients experience abdominal pain as a prominent symptom:
- 50-70% of patients report abdominal pain during active disease flares, making it one of the cardinal symptoms alongside bloody diarrhea, urgency, and increased stool frequency 1
- Abdominal pain was rated as having a large impact on quality of life by 56% of UC patients in a survey of 1,030 patients, ranking third after urgency (72%) and fatigue (59%) 1
- The pain is often relieved by defecation and may be accompanied by rectal urgency and tenesmus 2
- Pain severity varies with disease extent and activity, with moderate to severe UC patients experiencing more significant abdominal pain than those with mild disease 1
Pain During Remission
Patients in clinical remission should experience minimal to no abdominal pain:
- In patient surveys assessing remission thresholds, patients most commonly voted that they would accept no abdominal pain to consider themselves in remission 1
- However, gastroenterologists were more lenient, most commonly accepting mild abdominal pain occurring occasionally (less than 2 days per week) as compatible with remission 1
- This discrepancy highlights that patients have stricter expectations for pain control than their physicians 1
Pain Characteristics and Causes
The etiology of pain in UC is multifactorial and not always directly linked to active inflammation:
- Inflammatory causes include active mucosal inflammation, stricturing disease, fistulae, and fissures 1
- Non-inflammatory causes include adhesions, fibrotic strictures, or co-existing functional gastrointestinal symptoms such as IBS 1
- Extra-intestinal manifestations, particularly arthropathies (prevalence up to 46%), can contribute to overall pain burden 1
- A subset of patients continue to experience pain without evidence of active disease on investigation, which may represent functional symptoms, anxiety, or depression 1
Clinical Assessment and Management Implications
Pain assessment should be incorporated into comprehensive disease evaluation:
- The Mayo Score includes a physician's global assessment but does not have a specific pain subscore, though pain influences overall disease activity assessment 1
- Recent consensus guidelines recommend that comprehensive disease control should include assessment of abdominal pain as reported by patients, measured on a numerical scale 1
- Pain can be unpredictable in nature and provoke significant anxiety, influencing health-related quality of life even when other symptoms are controlled 1
Treatment Considerations
Pain management requires identifying the underlying cause:
- Optimizing IBD therapy is the primary approach when pain is inflammatory in nature 1
- Opioids should be used with extreme caution due to risks of dependence, serious infection, mortality, narcotic bowel syndrome, and gut dysmotility 1
- Tricyclic antidepressants may serve as useful adjuvant analgesics for chronic pain 1
- Cognitive and behavioral psychotherapy may help patients cope with pain and improve quality of life, though it does not appear to influence disease course 1
Common Pitfalls
- Do not assume pain always correlates with endoscopic activity—some patients have pain without inflammation, while others have inflammation without significant pain 1
- Avoid dismissing persistent pain in patients with endoscopically inactive disease—functional symptoms, psychological factors, and extra-intestinal manifestations require empathetic evaluation and management 1
- Recognize that patient and physician thresholds for acceptable pain levels differ significantly—patients expect complete pain resolution for remission, while physicians may accept mild intermittent pain 1