Editorial: Understanding Factors Associated With Abdominal Pain in Ulcerative Colitis—No Surprises But the Usual Suspects Need Greater Attention

Abstract

Pain control is often multidisciplinary and resource-intensive. Pain may be a poorly controlled symptom of ulcerative colitis (UC) culminating in significant patient dissatisfaction. The multicohort study exploring factors associated with abdominal pain in active and quiescent UC highlights the importance of attempting to prevent pain in UC. This may be achieved through understanding the risk factors that may lead to severe pain. Succeeding in this aim may allow us to minimise pain and improve the quality of life in those with UC.

Van Gils et al. [1] suggested active disease, female gender and anxiety/depression are positively associated with severe abdominal pain. The most significant association was observed in the second cross-sectional cohort where the female gender was positively associated with abdominal pain (adjusted odds ratio [aOR] 2.03; p < 0.01). This is consistent with the association of female gender and pain in other gastrointestinal diseases such as intestinal dysmotility and irritable bowel syndrome [2, 3]. In the same cohort, active disease and anxiety were both associated with abdominal pain with aORs of 2.68 (p < 0.001) and 1.99 (p < 0.001) aligning with growing understanding that the gut-brain axis is likely to interact to create the sensation of pain though the activation of visceral and nociceptive pain receptors [4, 5]. It is interesting that concurrent use of medications such as oral 5-ASA, thiopurines and anti-TNF agents were not associated with abdominal pain severity (aORs 1.27, 0.82, 1.18, respectively) as these may be considered a proxy for more severe disease and, hence, the expectation of a greater pain burden. One could argue that none of the other predictive factors associated with pain is particularly surprising. Despite this, the key strength of this study included the use of homogenous survey parameters and concordant results across the three cohorts. This provides a timely reminder that these factors play a significant role in abdominal pain. Furthermore, some of these are potentially modifiable and hence are treatable targets.

Despite the robustness of this study, a major limitation was the appropriateness of using the GSRS survey as a proxy for pain severity in patients with UC as it is more specific for upper gastrointestinal conditions [6, 7]. A more directed validated questionnaire such as Ulcerative Colitis Patient-Reported Outcomes Signs and Symptoms (UC-PRO/SS) [8] may allow for greater accuracy when recording pain from UC patients. Other limitations included the lack of granularity regarding the use of concurrent medications such as antispasmodics, acetaminophen, opiates and antibiotics. These may mask pain and indicate alternative underlying pathologies. Other tangible factors such as social stress, sleep quality, diet, previous abdominal surgeries and gut microbiome are all foreseeable predictors of abdominal pain severity in UC.

This study has set a precedent and offers a platform for improvement in future studies to incorporate new factors that predict abdominal pain in UC. It has highlighted that abdominal pain is common and troublesome for those with UC. A greater focus on mitigating against modifiable factors predictive of pain may help alleviate this.

Weilun Gao: writing – original draft, writing – review and editing, data curation. Jonathan P. Segal: conceptualization, writing – original draft, writing – review and editing, supervision, data curation.

Jonathan P. Segal has received speaker fees for Takeda, Sandoz, Pfizer and Bristol Myers Squibb. He has received conference sponsorship from Takeda, Pfizer and Bristol Myers Squibb. He has received an unrestricted research grant from Tillotts. Weilun Gao reports no conflicts of interest.

This article is linked to Van Gils et al papers. To view these articles, visit https://doi.org/10.1111/apt.18344 and https://doi.org/10.1111/apt.18380.