Medicine (St Vincent's) - Theses

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Type: PhD thesis × Subject: inflammatory bowel disease × Start date: 2020 × End date: 2022 ×

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    Behavioural treatment for functional bowel symptoms in inflammatory bowel disease
    Khera, Angela Jane ( 2022)
    Inflammatory bowel diseases (IBD) are chronic relapsing and remitting inflammatory diseases of the gastrointestinal tract, with the most common sub-types being Crohn’s disease and ulcerative colitis. Despite achieving disease remission patients with inflammatory bowel disease often experience persisting bowel symptoms, considered “functional in nature”, including increased bowel frequency, urgency, faecal incontinence, constipation (low bowel frequency or difficult rectal emptying), abdominal pain, bloating, and anorectal pain. Some patients with ulcerative colitis require major surgery, involving colectomy and construction of a neo-rectum or ileoanal pouch. Many continue to have similar long-term symptoms. Poor health-related quality of life, anxiety, depression, and health-seeking behaviour are associated with these functional bowel disorders in patients with IBD. Behavioural treatment for bowel dysfunction incorporates education, muscular and sensory rehabilitation, defaecation training, practical management strategies, and psychological support. It is of proven efficacy in the non-IBD population but the evidence in patients with IBD is extremely limited. The primary aim of this thesis is to determine the efficacy of behavioural treatment, including pelvic floor muscle training, for persistent bowel symptoms in patients with quiescent IBD or an ileoanal pouch. These studies have demonstrated that behavioural treatment is an effective management strategy for patients with quiescent IBD, in both public and private healthcare settings. It reduces symptom severity and improves health-related quality of life. The long-term findings of the prospective LIBERATE study found that most patients had maintained the improvement in symptoms at 12 months after completing treatment. The cross-sectional study of patients with an ileoanal pouch confirms that many do have long-term pouch dysfunction, and most have learned to live with it. The preliminary findings of the randomised controlled RAP trial, for patients undergoing pouch surgery, demonstrate statistically significant superiority of peri-operative physiotherapist-led behavioural intervention over standard or usual care, with regard to symptoms, psychological well-being, and quality of life. This thesis includes the first studies examining pelvic floor muscle function in patients with IBD using real-time ultrasound. They are also the first studies to use transperineal ultrasound as an outcome measure following pelvic floor behavioural treatment for faecal incontinence or defaecatory dysfunction. Transperineal ultrasound identified pelvic floor muscle dysfunction and accurate displacement, although these were not associated with the primary outcomes of treatment. Real-time ultrasound examination was well tolerated and an excellent non-invasive biofeedback tool for patients with IBD and pelvic floor muscle dysfunction. The findings from this thesis provide a clear rationale for behavioural treatment to be offered to patients, particularly when other therapies have failed. This work also suggests that identifying functional bowel symptoms earlier and treating them effectively may minimise the impact on psychological well-being and quality of life, particularly for those undergoing major pouch surgery. Improving the recognition of functional bowel symptoms and providing evidence for behavioural treatment as a safe and effective management option has the potential to alter the current model of care and reduce the personal and economic burden of IBD.