Among patients with inflammatory bowel disease (IBD), abdominal pain is a common and frustrating symptom with multifaceted pathophysiology and can be associated with significant emotional suffering, disability, and high medical costs. “One of the challenges with managing pain in IBD is that many overlapping factors influence patients’ perception of pain in IBD,” explains Arvind Iyengar Srinath, MD. “These include inflammatory, obstructive, psychological, psychosocial, and neurobiological factors.”
Abdominal pain has traditionally been attributed to gut inflammation during a disease flare. However, studies suggest that many patients have disabling abdominal pain even while they are in remission. “We are currently learning more and more about the complex nature of pain in IBD,” says Dr. Srinath. “Considering the multifaceted causes of abdominal pain in patients with IBD and its potentially devastating consequences, it is essential that individualized management approaches be utilized to address the various contributions of each of these factors.”
Caring for Patients: IBD vs IBS
Dr. Srinath recommends that all clinicians recognize and appreciate the potential overlap of symptoms between IBD and irritable bowel syndrome (IBS). “Pain management should be customized,” he says. “There has been an influx of improved medical treatments for disease activity in IBD, but there is also a growing recognition of functional abdominal pain, as in IBS, within the IBD population.” Currently, there is a paucity of data on pharmacologic, behavioral, and procedural methods to alleviate abdominal pain in IBD. However, Dr. Srinath notes that there is a wide spectrum of potential treatments that can
be considered in patients depending on the contributions of factors that are associated with abdominal pain perception in IBD (Figure 1).
“Developing a strong patient–clinician alliance is critical, especially when pain occurs in the absence of objective evidence of inflammation.”
Patients with unrelenting abdominal pain are among the most challenging for clinicians to manage. When abdominal pain occurs in the absence of inflammation, it can lead to multiple provider visits and high medical costs in search of inflammation (which may not necessarily be present) as a cause for the pain, and potential patient frustration, says Dr. Srinath. “Developing a strong patient–clinician alliance is critical, especially when pain occurs in the absence of objective evidence of inflammation,” he says. “There is no ‘quick fix’ for many patients. They will need to be informed that care efforts to successfully manage abdominal pain are an ongoing process. The clinician plays a vital role in articulating these messages to patients and gaining their trust to help them identify causes and manage their pain.”
Other Useful Approaches for IBD Pain
In addition to pharmacologic treatments—with possible options including antispasmodics—several non-pharmacologic approaches may also be useful when caring for pain in IBD. It is sometimes difficult to differentiate between inflammatory, structural, or psychological mechanisms for pain, but psychological approaches (eg, cognitive behavioral therapy or hypno-therapy) and psychosocial strategies (eg, modifying coping skills and managing stress) may be of help. Less is known about the efficacy of procedural interventions for treating abdominal pain, but research within other gastrointestinal conditions, where abdominal pain is predominant, is continuing to explore the use of acupuncture, nerve blocks, and transcutaneous electrical nerve stimulation (TENS) for pain. “These are not considered first-line treatments,” Dr. Srinath says.
Important Considerations When Caring for IBD Pain
According to Dr. Srinath, clinicians caring for pain in IBD patients should always consider the overlap of visceral hypersensitivity and compounding psychological and psychosocial factors when screening for inflammation and other IBD factors that can lead to pain (Figure 2). “To develop an effective care plan, clinicians should tailor treatments to the varying and unique contributions of overlapping factors,” he says. “Unfortunately, there are not many pharmacologic options for pain management outside of antispas-modics and traditional disease-modifying medication.”
If inflammation is not felt to be a major cause of pain, Dr. Srinath says physicians should consider using behavioral treatment. “Clinicians should keep in mind the clinical degree of visceral hypersensitivity and the impact of abdominal pain on the patient’s life. Coping skills and stress management teaching are effective, but these should be considered only as adjunctive therapies. From a procedural standpoint, we have insufficient data from the literature to recommend acupuncture, spinal nerve blockage, or TENS in patients with IBD at this point.”
The hope, Dr. Srinath says, is that future research will lead to the development of better treatments for abdominal pain in IBD. “We need more data on the underlying mechanisms that drive abdominal pain in patients with IBD and on other potentially beneficial treatments. Many treatments appear to be promising, but the field must continue to move forward if we are to fully understand this phenomenon and enhance patient care.”
Readings & Resources (click to view)
Srinath IL, Walter C, Newara MC, Szigethy EM. Pain management in patients with inflammatory bowel disease: insights for the clinician. Ther Adv Gastroenterol. 2012;5:339-357. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3437534/pdf/10.1177_1756283X12446158.pdf.
Farrokhyar F, Marshall JK, Easterbrook B, et al. Functional gastrointestinal disorders and mood disorders in patients with inactive inflammatory bowel disease: prevalence and impact on health. Inflamm Bowel Dis. 2006;12:38-46.
Szigethy E, Kenney E, Carpenter J, et al. Cognitive-behavioral therapy for adolescents with inflammatory bowel disease and subsyndromal depression. J Am Acad Child Adolesc Psychiatry. 2007;46:1290-1298.
Long MD, Barnes EL, Herfarth HH, Drossman DA. Narcotic use for inflammatory bowel disease and risk factors during hospitalization. Inflamm Bowel Dis. 2012;18:869-876.
Long MD, Drossman DA. Inflammatory bowel disease, irritable bowel syndrome, or what? A challenge to the functional-organic dichotomy. Am J Gastroenterol. 2010;105:1796-1798.
Schirbel A, Reichert A, Roll S, et al. Impact of pain on health-related quality of life in patients with inflammatory bowel disease. World J Gastroenterol. 2010;16:3168-3177.