Journal of Crohn's and Colitis Advance Access published May 23, 2015 Journal of Crohn's and Colitis, 2015, 1–1 doi:10.1093/ecco-jcc/jjv070 Letter to the Editor
Letter to the Editor Rectal hypersensitivity in patients with quiescent ulcerative colitis Casanova MJ, Santander C, Gisbert JP Gastroenterology Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa [IISIP], and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBEREHD], Madrid, Spain Corresponding author: María José Casanova González, MD, PhD Marcenado 7, 2B, CP 28002 Madrid, Spain. Tel.: 34-913093011; fax: 34-914022299; email: [email protected] Faecal urgency and faecal incontinence in patients with ulcerative colitis [UC] cannot always be explained by the presence of mucosal inflammation. We report two cases of patients diagnosed with UC with mucosal healing, who developed faecal urgency and faecal incontinence secondary to rectal hypersensitivity. A 40-year-old man was diagnosed with left-sided UC in 2005. After a step-up therapeutic approach, the remission of disease was finally induced with infliximab. After 3 years in remission, the patient complained of faecal incontinence. After a colonoscopy, disease activity was ruled out. Anorectal manometry was performed and revealed that both the sensation of urgency to defaecate and the maximum tolerable volume were below the reference values. The patient was diagnosed with rectal hypersensitivity. As symptoms might be worsened by the administration of rectal 5-aminosalicylic acid [ASA], the rectal treatment was stopped and the faecal symptoms disappeared. A-56-year-old man was diagnosed with UC in 2005 and started azathioprine in 2008 owing to cortico-dependency. After 2 years in remission, he complained of faecal urgency and faecal incontinence. A colonoscopy revealed quiescent disease. Anorectal manometry was performed and showed that the maximum tolerable volume was below the reference values and that the rectal sensory threshold was decreased. The patient was diagnosed with rectal hypersensitivity. Treatment with amitriptyline 25 mg/day was started and, after 6 months of treatment, the patient became asymptomatic. Patients with UC may have colonic motility dysfunction that can play an important role in the genesis of symptoms.1 Rectal sensation is an important factor in the defaecatory process. Distension of the rectum initiates rectal wall contractions and creates a desire to defaecate. Anorectal dysfunction is a form of colonic dysmotility that produces faecal urgency and faecal incontinence in patients with quiescent UC, even in the absence of disease activity and inflammation.2 This should be suspected in patients who complain about these symptoms despite having a normal endoscopy. It is thought that rectal hypersensitivity may be responsible for the heightened perception of rectal filling and this may act as a trigger for faecal urgency.3
There are a few options for the management of rectal hypersensitivity, that include biofeedback or pharmacological treatment such as loperamide or tricyclic antidepressants.4 Amitriptyline is a tricyclic antidepressant and it is believed that this drug decreases pain ratings in response to rectal distension by reducing activation of a specific area of the brain that is activated during painful rectal distention.5 In conclusion, anorectal hypersensitivity is a rectal dysfunction that can be present in patients with UC. It should be suspected when symptoms such as faecal urgency and faecal incontinence persist after ruling out disease activity, in order to provide appropriate treatment to the patient and to improve both their symptoms and their quality of life.
Funding CIBEREHD is funded by Instituto de Salud Carlos III.
Conflict of interest None.
References 1. Snape WJ Jr. The role of a colonic motility disturbance in ulcerative colitis. Keio J Med 1991;40:6–8. 2. Torres J, Billioud V, Sachar DB, Peyrin-Biroulet L, Colombel JF. Ulcerative colitis as a progressive disease: the forgotten evidence. Inflamm Bowel Dis 2012;18:1356–63. 3. Chan CL, Scott SM, Williams NS, Lunniss PJ. Rectal hypersensitivity worsens stool frequency, urgency, and lifestyle in patients with urge faecal incontinence. Dis Colon Rectum 2005;48:134–40. 4. Wang JY, Abbas MA. Current management of faecal incontinence. Perm J 2013;17:65–73. 5. Morgan V, Pickens D, Gautam S, Kessler R, Mertz H. Amitriptyline reduces rectal pain related activation of the anterior cingulate cortex in patients with irritable bowel syndrome. Gut 2005;54:601–7.
Copyright © 2015 European Crohn’s and Colitis Organisation (ECCO). Published by Oxford University Press. All rights reserved. For permissions, please email: [email protected]
1
Letter to the Editor Rectal hypersensitivity in patients with quiescent ulcerative colitis Casanova MJ, Santander C, Gisbert JP Gastroenterology Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa [IISIP], and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBEREHD], Madrid, Spain Corresponding author: María José Casanova González, MD, PhD Marcenado 7, 2B, CP 28002 Madrid, Spain. Tel.: 34-913093011; fax: 34-914022299; email: [email protected] Faecal urgency and faecal incontinence in patients with ulcerative colitis [UC] cannot always be explained by the presence of mucosal inflammation. We report two cases of patients diagnosed with UC with mucosal healing, who developed faecal urgency and faecal incontinence secondary to rectal hypersensitivity. A 40-year-old man was diagnosed with left-sided UC in 2005. After a step-up therapeutic approach, the remission of disease was finally induced with infliximab. After 3 years in remission, the patient complained of faecal incontinence. After a colonoscopy, disease activity was ruled out. Anorectal manometry was performed and revealed that both the sensation of urgency to defaecate and the maximum tolerable volume were below the reference values. The patient was diagnosed with rectal hypersensitivity. As symptoms might be worsened by the administration of rectal 5-aminosalicylic acid [ASA], the rectal treatment was stopped and the faecal symptoms disappeared. A-56-year-old man was diagnosed with UC in 2005 and started azathioprine in 2008 owing to cortico-dependency. After 2 years in remission, he complained of faecal urgency and faecal incontinence. A colonoscopy revealed quiescent disease. Anorectal manometry was performed and showed that the maximum tolerable volume was below the reference values and that the rectal sensory threshold was decreased. The patient was diagnosed with rectal hypersensitivity. Treatment with amitriptyline 25 mg/day was started and, after 6 months of treatment, the patient became asymptomatic. Patients with UC may have colonic motility dysfunction that can play an important role in the genesis of symptoms.1 Rectal sensation is an important factor in the defaecatory process. Distension of the rectum initiates rectal wall contractions and creates a desire to defaecate. Anorectal dysfunction is a form of colonic dysmotility that produces faecal urgency and faecal incontinence in patients with quiescent UC, even in the absence of disease activity and inflammation.2 This should be suspected in patients who complain about these symptoms despite having a normal endoscopy. It is thought that rectal hypersensitivity may be responsible for the heightened perception of rectal filling and this may act as a trigger for faecal urgency.3
There are a few options for the management of rectal hypersensitivity, that include biofeedback or pharmacological treatment such as loperamide or tricyclic antidepressants.4 Amitriptyline is a tricyclic antidepressant and it is believed that this drug decreases pain ratings in response to rectal distension by reducing activation of a specific area of the brain that is activated during painful rectal distention.5 In conclusion, anorectal hypersensitivity is a rectal dysfunction that can be present in patients with UC. It should be suspected when symptoms such as faecal urgency and faecal incontinence persist after ruling out disease activity, in order to provide appropriate treatment to the patient and to improve both their symptoms and their quality of life.
Funding CIBEREHD is funded by Instituto de Salud Carlos III.
Conflict of interest None.
References 1. Snape WJ Jr. The role of a colonic motility disturbance in ulcerative colitis. Keio J Med 1991;40:6–8. 2. Torres J, Billioud V, Sachar DB, Peyrin-Biroulet L, Colombel JF. Ulcerative colitis as a progressive disease: the forgotten evidence. Inflamm Bowel Dis 2012;18:1356–63. 3. Chan CL, Scott SM, Williams NS, Lunniss PJ. Rectal hypersensitivity worsens stool frequency, urgency, and lifestyle in patients with urge faecal incontinence. Dis Colon Rectum 2005;48:134–40. 4. Wang JY, Abbas MA. Current management of faecal incontinence. Perm J 2013;17:65–73. 5. Morgan V, Pickens D, Gautam S, Kessler R, Mertz H. Amitriptyline reduces rectal pain related activation of the anterior cingulate cortex in patients with irritable bowel syndrome. Gut 2005;54:601–7.
Copyright © 2015 European Crohn’s and Colitis Organisation (ECCO). Published by Oxford University Press. All rights reserved. For permissions, please email: [email protected]
1
