Psychosocial Factors Affect Abdominal Pain in Patients with IBD in Remission

Zlatan Mujagic, MD, PhD

Credit: Maastricht University

Findings from a recent study are providing an overview of the association between abdominal pain and psychosocial factors among patients with inflammatory bowel disease (IBD) in remission.

Results of the study, which included more than 500 participants, suggest abdominal pain was present in nearly 50% of patients included in the study, with multiple factors, including sex, fatigue, and depressive symptoms, associated with increased risk of abdominal pain in this patient population.¹

“Data on the prevalence, characteristics, dynamics and triggers of chronic abdominal pain in IBD patients in remission are sparse, yet needed for the identification of novel treatment targets,” wrote investigators.¹ “A better understanding of abdominal pain and the associated factors will potentially lead to more personalised and effective therapies, and eventually a reduction of societal costs and improvement of quality of life in affected subjects.”

As many as 1.6 million US adults are affected by ulcerative colitis (UC) and Crohn disease (CD), the 2 inflammatory conditions that make up IBD. Abdominal pain is a common symptom of IBD, although patients may indefinitely experience periods of remission followed by flare-ups.²

To investigate the association of clinical, lifestyle, and psychosocial factors with abdominal pain in patients with IBD in remission, senior investigator Zlatan Mujagic, MD, PhD, of the division of gastroenterology and hepatology at Maastricht University Medical Center in the Netherlands, and a team of investigators conducted a prospective multicenter study enrolling consecutive patients with IBD from Maastricht University Medical Centre and Zuyderland Medical Centre. Data was collected between January 1, 2020 and July 1, 2021, using myIBDcoach, an established remote monitoring platform for IBD. To be included in the study, patients were required to have CD or UC, be 18-75 years of age, and be in biochemical remission, defined as fecal calprotectin <150 μg/g.¹

Patients were excluded from analysis if they had abdominal pain scores without a known fecal calprotectin level, their disease state anytime during the study period was considered to be active, no fecal calprotectin levels during the study period were known, or the data regarding abdominal pain was incomplete.¹

In total, 559 patients were identified. Of this group, investigators excluded 130 patients due to active disease during the study period. Among the remaining participants, 429 (76.7%) remained in biochemical remission, 198 (46.2%) of which fulfilled the criteria for chronic abdominal pain.¹

Investigators divided the cohort into 2 groups, IBDremissionPain+ (n = 198) and IBDremissionPain- (n = 231), based on abdominal pain scores. To be in the IBDremissionPain+ group, patients were required to have an abdominal pain score ≥3 on a 10-point numeric rating scale on at least one-third of all assessments during the 18 month study period. If these criteria were not met, the patient was assigned to the IBDremissionPain- group. Compared to those in the IBDremissionPain- group, those in the IBDremissionPain+ group were more likely to be female (71.2% vs 45.9%, P < .001), younger (47.12 years vs 50.53 years, P = .014), and have a greater BMI (26.71 vs 25.79, P = .031).¹

During the 18-month study period, patient-reported outcome measures for abdominal pain, general wellbeing, IBD-control, lifestyle, and psychosocial factors were assessed every 1 to 3 months using myIBDcoach. General well-being (6.26 vs 7.70, P < .001) and perceived IBD control (6.56 vs. 8.35, P < .001) were on average lower in IBDremissionIPain+ patients.¹

Investigators used a linear mixed model with abdominal pain as the dependent factor and time as the repeated factor to analyze the association of potential risk factors with abdominal pain over time. A targeted post-hoc 3-factor model was also constructed to analyze the multivariable effect of anxiety symptoms, depressive symptoms, and perceived stress on abdominal pain over time.¹

Upon analysis, sex (β, 0.929; 95% CI, 0.572 to 1.285), disease entity (β, −0.593; 95% CI, −0.949 to −0.238), anxiety (β, 0.382; 95% CI, 0.230 to 0.534) and depressive (β, 0.459; 95% CI, 0.335 to 0.584) symptoms, fatigue (β, 0.275; 95% CI, 0.238 to 0.313), perceived stress (β, 0.122; 95% CI, 0.068 to 0.176], and life events (β, 0.832; 95% CI, 0.463 to 1.201) were associated with abdominal pain over time in the univariable analysis for the entire cohort (all P < .001).¹

In multivariate analysis, female sex (β, 0.492; P = .002), UC (β, −0.416; P = .007) depressive symptoms (β, 0.174; P = .021), fatigue (β, 0.242; P < .001) and life events (β, 0.375; P = 0.023) were associated with abdominal pain over time, but anxiety symptoms and perceived stress were no longer statistically significantly associated with abdominal pain over time. Depressive symptoms (β, 0.381; P < .001) and perceived stress (β, 0.101; P < .001) had a statistically significant association with abdominal pain over time in a targeted post-hoc three-factor model for the entire cohort.¹

In the IBDremissionPain+ group, investigators noted disease entity (β, −0.482; 95% CI, −0.909 to −0.054; P = .027), anxiety symptoms (β, 0.272; 95% CI, 0.072 to 0.472; P = .008), depressive symptoms (β, 0.302; 95% CI, 0.128 to 0.477; P < .001), and fatigue (β, 0.290; 95% CI, 0.223 to 0.356; P < .001) were associated with abdominal pain over time. In multivariable analysis, investigators pointed out only fatigue (β, 0.287; P < .001) still had a statistically significant association with abdominal pain over time.¹

“While the exact modulating effects between abdominal pain and psychological factors remain challenging to unravel, the results of the current study are indicative for a pertinent role for psychosocial factors and their interplay on abdominal pain in IBD in remission,” investigators concluded.¹ “Targeting psychosocial factors in IBD patients in remission is needed to improve pain outcomes.”

References:

1. Janssen LM, Rezazadeh Ardabili A, Romberg-Camps MJL, et al. Abdominal pain in patients with inflammatory bowel disease in remission: A prospective study on contributing factors. Aliment Pharmacol Ther. 2023; 00: 1–11. https://doi.org/10.1111/apt.17718
2. Johns Hopkins Medicine. Inflammatory Bowel Disease (IBD). Health. Accessed September 20, 2023. https://www.hopkinsmedicine.org/health/conditions-and-diseases/inflammatory-bowel-disease