Gut, 1988, 29, 342-345
`
`Symptomsandstool patterns in patients with
`ulcerative colitis
`
`SS C RAO, C D HOLDSWORTH, AND N W READ
`
`From the Gastrointestinal Unit, Royal Hallamshire Hospital, Sheffield
`
`SUMMARY Theprevalence of symptomsand stool patterns was assessed prospectively in 96 patients
`with ulcerative colitis subdivided according to the extent and activity of the disease. Increased
`frequency of defecation (83%), urgency (85%), a feeling of incomplete evacuation (78%) and
`tenesmus (63%) were the most frequent symptoms experienced by patients with activecolitis. All
`weresignificantly more common (p<0-001) in patients with active than quiescent colitis and their
`prevalence was similar in those with total and distal colitis, indicating that these symptoms are
`related to an inflamed andirritable distal colon. Twenty seven per cent of patients with activecolitis
`voided hardstools indicative of constipation, however, and this was more commonin active, than
`quiescentcolitis (p<0-05). This feature is probably secondaryto faecalstasis in the proximal colon,
`and an apt description of the bowel disturbance in ulcerative colitis, irrespective of the extent of
`disease is that the colon suffers from proximal constipation anddistalirritability.
`
`ment the prevalence of symptomsandstool patterns
`in three patients.
`
`Methods
`
`For a condition in which change of bowel habit is a
`major manifestation, there is a surprising dearth of
`objective data on bowel symptoms in ulcerative
`colitis, and this is reflected by the very inadequate
`and poorly referenced accounts in many standard
`PATIENTS
`
`textbooks of medicine and_gastroenterology.
`One hundred and ten assessments werecarried outin
`Althoughit is often assumed that the patient with
`active colitis usually has diarrhoea, there are no
`96 patients with histologically proven ulcerative
`colitis. The clinical details are shown in the Table.
`systematic studies of stool weight and frequency.
`Constipation has been mentioned in someclinical
`The disease was judged to be active, if sigmoido-
`accounts'* but many descriptions have ignored this
`scopic appearanceandhistology of a biopsy ofrectal
`mucosashowed evidenceofactive inflammation and
`symptom.°’ In a small series, Engel’ observed that
`44% of colitics were constipated at the time of
`the severity of colitis was categorised in accordance
`with Truelove and Witts criteria." The extent of the
`presentation, and in a larger retrospective enquiry,
`disease wasassessedby radiology and sigmoidoscopy
`constipation was reported by 20% of patients.* The
`concept of faecal stasis in colitis was extended by
`and wastermeddistalif it did not extend proximalto
`Lennard-Joneset al,°"® and in a retrospective case
`the splenic flexure. Sixty patients had active colitis
`and 50 had quiescent colitis and 14 were assessed
`record analysis it was estimated that 15%of colitics
`exhibited this feature." During the course of physio-
`during active and quiescent phasesof their disease.
`logical studies of patients with ulcerative colitis, we
`Ofpatients withdistal colitis, four with active disease
`and three with quiescent disease had proctitis only.
`observed that transit through the small intestine and
`proximal colon was paradoxically slow,” and this
`Of the 26 patients with active total colitis, five had
`reinforced our ownclinical impression that constipa-
`mild colitis, 10 moderately severe colitis and 11
`tion is a frequent problem. In order to understand the
`severe colitis. Of the 34 patients with active distal
`nature of the bowel disturbance in patients with
`colitis, 12 had mild colitis, 16 moderately severe
`colitis and six severecolitis.
`ulcerative colitis, we set out to systematically docu-
`Address for correspondence: Dr C D Holdsworth, FRCP, Consultant
`Physician, Floor J, Royal Hallamshire Hospital, Sheffield $10 2JF.
`Received for publication 24 August 1987.
`
`SYMPTOM QUESTIONNAIRE
`All patients completed a symptom questionnaire in
`342
`
`MSNExhibit 1048 - Page 1 of 4
`MSNv.Bausch - IPR2023-00016
`
`

`

`Symptoms andstoolpatterns in patients with ulcerative colitis
`
`343
`
`Table 1 Clinical details and the prevalence ofstoolpatterns and bowel symptoms,in patients with ulcerativecolitis,
`subdivided accordingto the extent and activity ofdisease
`
`
`Studied (n)
`Men/women
`Age(years)*
`Durationofcolitis (years)*
`Daily stool frequency*
`Nocturnaldefecation
`Predominant stool consistency
`Unformed
`Formed
`Hard
`Symptoms
`Urgency
`Incomplete evacuation
`Tenesmus
`Pain
`Analsoreness
`Incontinence
`
`Totalcolitis
`
`Active
`
`26
`10/16
`48 (19-76)
`7(0-5-21)
`5(4-9)t
`21 (81%)t
`
`17(65%)t
`4(15%)t
`5 (19%)
`
`24(92%)t
`20 (77% )t
`18 (69%)+
`12(46%)+
`13 (50% )+
`8(31%)t
`
`Quiescent
`
`19
`9/10
`5020-79)
`8 (0-6-22)
`2 (1-3)
`0
`
`3 (16%)
`15 (79%)
`1(5%) NS
`
`2(11%)
`3 (16%)
`2 (11%)
`2(11%)
`211%)
`0
`
`Distalcolitis
`
`Active
`
`34
`19/15
`46 (20-79)
`6 (0-4-22)
`4(2-6)t
`19 (56% )+
`
`15 (44% )t
`8(23%)+
`11 (33%)8
`
`27 (79%)
`27 (79%)t
`20 (59%)+
`18 (53%)+
`11 (32%)+
`6(18%)+
`
`Quiescent
`
`31
`13/18
`48 (20-80)
`8 (0-6-23)
`1(1-3)
`0
`
`2(7%)
`26 (84%)
`3(9%)
`
`5 (16%)
`6(19%)
`310%)
`5 (16%)
`2 (6%)
`0
`
`*=data expressed as median(range); t=significantly different from quiescenttotalcolitis (p<0-01); +=significantly different from quiescent
`distal colitis (p<0-01); §=significantly different from quiescentdistal colitis (p<0-05); NS=notsignificant.
`
`which they indicated the presence or absenceofsix
`symptoms
`related to defecation. These were:
`(1) urgency (an irresistible and urgent desire to
`defecate), (2) feeling of incomplete evacuation (a
`strong andpersistent desire to evacuate after defeca-
`tion), (3) tenesmus(continualinclination to evacuate
`bowels accompanied bypainful straining), (4) pain
`(lower abdominal orrectal pain, with or without any
`relation to defecation), (5) perianal soreness (intense
`discomfort or itching of the perianal skin), (6) faecal
`incontinence (inability to control defecation volun-
`tarily resulting in leakage of motions and/orsoiling of
`garments). A clear explanation of each symptom was
`providedat the timeofthe interview.
`In addition, all patients were asked if their stools
`were predominantly loose, formed or hard, if they
`were associated with blood and mucus, and if they
`had to wake upat night to defecate. Their average
`daily bowel frequencywasalso recorded.
`
`STATISTICAL ANALYSIS
`
`The differences in the stool consistency and in
`the prevalence of symptoms between active and
`quiescent disease were analysed using x’ tests. Data
`on stool frequency were compared by Wilcoxon’s
`rank-sum tests.
`
`Results
`
`PREVALENCE OF SYMPTOMS
`
`Theprevalence of the six bowel symptomsin patients
`
`with ulcerative colitis is shown in the Table. Patients
`with active disease exhibited a higher prevalence
`of urgency, a feeling of incomplete evacuation,
`tenesmus, pain, anal soreness and faecal incontin-
`ence, comparedwith patients with quiescentcolitis.
`The prevalence of these symptoms did not vary
`significantly with the extent of the disease (Table).
`Fourteen patients (women=12, men=two) with
`active colitis reported faecal incontinence. All except
`two (one woman, one man) were over 60 years of
`age.
`
`STOOL PATTERNS
`As would be expected, the frequency of defecation
`was higher in patients with active than quiescent
`colitis,
`irrespective of the extent of the disease
`(Table). Eighty three per centof patients with active
`colitis were defecating more than three times a day.
`No patient with quiescent colitis experienced this
`degree of stool frequency. Nocturnal defecation was
`reported by 81%of patients with active total colitis
`and 56% of patients with active distal colitis, but by
`none of the patients with quiescent colitis. There
`was nosignificant difference in the prevalence of
`nocturnal defecation betweenpatients with total and
`distal colitis.
`Ninety six per cent of patients with active colitis
`passed blood and mucusin their stools every day. In
`contrast only 8% of patients with quiescent disease
`occasionally passed blood and 12% occasionally
`passed mucusintheir stools.
`
`MSN Exhibit 1048 - Page 2 of 4
`MSNv. Bausch - IPR2023-00016
`
`

`

`344
`
`Rao, Holdsworth, and Read
`
`Although the proportion of stools which were
`unformed wassignificantly higher in patients with
`active than quiescentcolitis (Table), many patients
`with active disease passed formed orhardstools.
`A higher proportion of patients with active colitis
`(27%) than quiescent colitis (8% ) reported that their
`stools were hard (p<0-05), and this was true in both
`distal colitis and total colitis, although in the case of
`total colitis this did not reachstatistical significance
`(Table). Twooffour patients with active proctitis and
`one of three with quiescent proctitis voided hard
`stools. The hard stools of active colitis were always
`accompanied by blood and mucusand were associ-
`ated with symptoms of tenesmus and a feeling of
`incomplete evacuation.
`
`Discussion
`
`Although most patients with active colitis had
`increased stool frequency and were voiding blood
`and mucus in their stools,
`the results of stool
`consistency were surprising. Twenty eight of 60
`(47%) patients with active colitis reported they were
`passing formed stools and in as manyas 16 (27%)
`patients, the stools were hard. This showsthat liquid
`diarrhoeais by no meansa constant feature of active
`colitis. Instead, the passage of hard stools suggests
`that by this criterion at least a sizeable proportion of
`colitics are constipated. The observation that the
`passage of hard stools was more commonin patients
`with active than quiescent colitis suggests that in
`some patients hard stools are an index of disease
`activity. The existence of constipation in ulcerative
`colitis is supported by previous observations'**" but
`the frequency with which this occursandits relation-
`ship to the extent and activity of inflammation has
`never beenassessed prospectively. A large survey of
`450 patients published recently, has reported that
`only 3-5%of patients with colitis have constipationat
`the time of presentation." In this survey, the patients
`were asked to record their bowel habit as ‘normal’,
`‘diarrhoea’, or ‘constipation’. This form of assess-
`mentis unlikely to provide a clear picture, as most
`patients with colitis are often distracted by the
`frequent passage of blood and mucus.* If frequency
`of defecation is the sole criterion used,
`then the
`occurrence of constipation will be overlooked.
`The prevalence of important symptomsrelated to
`defecation has hitherto not been documented in
`patients with colitis. An urgent desire to defecate and
`a feeling of incomplete evacuation were reported by
`80-90%ofpatients with active colitis and by 10-15%
`of patients with quiescent colitis. Tenesmus was
`reported by 63%of patients indicating that painful
`straining during evacuation is an important and
`frequent manifestation of active colitis. The preval-
`
`ence of these and other symptoms assessed were
`similar in patients with total and distal colitis,
`suggesting that they are related to an inflameddistal
`colon. Tests of anorectal function have shownthat
`the rectum in patients with active colitis is hyper-
`sensitive’ (unpublished data), poorly compliant"
`and reacts excessively to intraluminal distension
`(unpublished data); features that could explain the
`symptoms of urgency and increased frequency of
`defecation.
`The occurrenceof nocturnal defecation and faecal
`incontinence invariably suggests active disease, as
`they were absent in patients with quiescent colitis.
`Eleven of 14 patients with incontinence were
`elderly women, andthis group of the population has
`been shown to be particularly susceptible to
`incontinence.” *
`Symptoms of increased bowel frequency, pain
`relieved by defecation, a feeling of incomplete
`evacuation and passage of mucushave beenreported
`to favour a positive diagnosis of irritable bowel
`syndrome.” As these symptoms are commonly
`presentin colitics, we agree with others” thatit is not
`possible to distinguish patients with functional bowel
`disturbance from those with organic boweldisease on
`the basis of these symptomsalone.
`Wehaverecently shown that patients with active
`colitis void small volumestools frequently, and have
`stasis in the proximalcolon and rapid transit through
`the rectosigmoid region, irrespective of the extent of
`colitis.” Our present study shows howthese changes
`in colonic function mayberelated to the symptomsof
`active disease, the proximal colonic stasis causing
`hard stools, and the irritable distal colon causing
`the more widely recognised frequent defecation,
`urgency,
`tenesmus, and a feeling of incomplete
`evacuation.
`
`Dr SSC Raois supported by a grant from the Special
`Trustees of the Former United Sheffield Hospitals.
`
`References
`
`1 Hurst AF. Ulcerative colitis. Guy’s Hosp Rep 1935; 85:
`317-55.
`2 BargenJA. In: Bargen JA, ed. Chronic ulcerative colitis.
`Springfield, Illinois: Charles C. Thomas, 1951.
`3 Engel GL.Studies ofulcerative colitis. II. The nature of
`the somatic process and the adequacy of psychosomatic
`hypotheses. Am J Med 1954; 16: 416-33.
`4 Shearman DJC. Ulcerative colitis. In: McLeod J, ed.
`Davidson’s principles
`and practice of medicine.
`Edinburgh: Churchill Livingstone, 1985: 321-6.
`5 Glickman RM. Inflammatory boweldisease: Ulcerative
`colitis and Crohn’s disease. In: Petersdorf RG, Adams
`RA, Braunwald E, et al, eds. Harrison’s principles of
`internal medicine. New York: McGraw-Hill Book
`Company, 1983: 1738-52.
`
`MSN Exhibit 1048 - Page 3 of 4
`MSNv. Bausch - IPR2023-00016
`
`

`

`Symptoms andstoolpatterns in patients with ulcerativecolitis
`
`345
`
`~
`
`10
`
`6 Truelove SC. Ulcerative Colitis. In: Weatherall DJ,
`Leadingham JGG, Warrell DA, eds. Oxford textbook of
`medicine. Oxford: Oxford University Press, 1985: 12,
`107-12.
`Cello JP, Meyer JH. Ulcerative colitis. In: Sleisenger
`MH, Fordtran JS, eds. Gastrointestinal disease. Patho-
`physiology, diagnosis, management. New York: WB
`Saunders, 1978: 1597-653.
`8 Sim M, Brooke BN. Ulcerative colitis. A test of
`psychosomatic hypothesis. Lancet 1958; i: 125-6.
`9 Lennard-Jones JE, Langman MJS, Jones, FA. Faecal
`stasis in proctocolitis. Gut 1962; 3: 301-S.
`Lennard-Jones JE, Cooper GW, Newell AC, Wilson
`CWE, Avery Jones F. Observations on idiopathic
`proctitis. Gut 1972; 3: 201-6.
`11 Jalan KN, Walker RJ, Prescott RJ, Butterworth STG,
`Smith AN, Sircus W. Faecal stasis and diverticular
`diseasein ulcerative colitis. Gut 1970; 11: 688-96.
`Rao SSC, Read NW, Brown C, Bruce C, Holdsworth
`CD. Studies on the mechanism of bowel disturbance in
`ulcerative colitis. Gastroenterology (in press).
`Truelove SC, Witts LJ. Cortisone in ulcerative colitis.
`Final report on a therapeutic trial. Br Med J 1955; ii:
`1041-8.
`
`12
`
`13
`
`14
`
`15
`
`16
`
`17
`
`18
`
`19
`
`20
`
`de Dombal FT, Myren J, Bouchier IAD, et al. Diagnosis
`of patients with inflammatory boweldisease — the value
`of clinical features.
`In: de Dombal FT, Myren J,
`Bouchier IAD, Watkinson G, eds. Inflammatory bowel
`disease —someinternational data andreflections. Oxford:
`Oxford University Press, 1986: 94-110.
`Farthing MJG, Lennard-Jones JE. Sensitivity of the
`rectum to distension and the anorectal distension reflex
`in ulcerative colitis. Gut 1978; 19: 64-9.
`Denis Ph, Colin R, GalmickeJP,et al. Elastic properties
`of the rectal wall
`in normal adults and in patients
`with ulcerative colitis. Gastroenterology 1979; 77:
`45-8.
`function in continent and
`Ihre T. Studies on anal
`incontinent patients. Scand J Gastroenterol 1974; 25:
`1-80.
`Bannister JJ, Abouzekry L, Read NW. Effect of aging
`on anorectal function. Gut 1987; 28: 353-7.
`Manning AP, Thompson WG, Heaton KW, Morris AF.
`Towards positive diagnosis of the irritable bowel. Br
`Med J 1978; 2: 653-4.
`Isgar B, Harman M, Kaye MD, Whorwell PJ.
`Symptomsof irritable bowel syndromein ulcerative
`colitis in remission. Gut 1983; 24: 190-2.
`
`MSNExhibit 1048 - Page 4 of 4
`MSNv.Bausch - IPR2023-00016
`
`