10/4/21, 9:39 PM Top tips: inflammatory bowel disease | Top tips | Guidelines in Practice

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Top tips: inflammatory bowel disease
By Dr Kevin Barrett | 29 April 2021

Dr Kevin Barrett offers 10 practical tips on the role of primary care in diagnosing and managing
inflammatory bowel disease

Read this article to learn more about:

identification of inflammatory bowel disease (IBD) and potential
differential diagnoses

identifying possible signs of severe disease or cancer that may

need urgent referral

important information to share with patients with IBD.

Dr Kevin Barrett
Key points

Implementation actions for clinical pharmacists in general practice

Guidelines Learning

After reading this article, ‘Test and reflect’ on your updated knowledge with our
multiple-choice questions. We estimate that this activity will take you 30 minutes—
worth 0.5 CPD credits.

Inflammatory bowel disease (IBD) is a relapsing-remitting chronic disease that primarily affects the
bowel, although extraintestinal manifestations in sites such as the skin, joints, and liver are
common.1,2 In 2018, the prevalence of IBD in the UK was approximately 1 in 140 people.3 Ulcerative
colitis is the most common subtype, followed by Crohn’s disease, then IBD-unclassified and
microscopic colitis.3–5 Patients may be affected by IBD at any age, although there is age-related
variability in the subtypes.3

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1. Recognise the main difference between IBS and IBD: inflammation

Irritable bowel syndrome (IBS) and IBD are frequently mistaken to be the same condition as there is
an overlap in the common symptoms. However, there is currently no detectable underlying
inflammation in IBS. IBS is thought to be an umbrella diagnosis for a range of functional bowel
disorders that include gut motility disturbance, visceral hypersensitivity, altered mucosal and immune
function, altered gut microbiota, and altered central nervous system processing.6 Many of these
issues co-exist in patients with IBD, but the key differentiator is that IBD always has an underlying
inflammatory component.7

2. Be vigilant for the key symptoms

Many patients present with the classical symptoms (weight loss and diarrhoea lasting for more than 4
weeks),8,9 and it is easy to suspect that that there is a non-infective cause. Nocturnal diarrhoea is a
key differentiator between organic and functional disorders so it is always worth asking this
question.7 In my experience, some patients, particularly children or those with upper gastrointestinal
Crohn’s disease, may only present with anaemia, failure to thrive, or extra-intestinal symptoms
without any change in their bowel habit; reaching a diagnosis can be more challenging in these
groups. Any patient who meets the NICE Guideline 12 criteria for suspected cancer (see Box 1) should
be referred via the suspected cancer pathway rather than via a suspected IBD pathway.8

Box 1: NICE criteria for suspected lower gastrointestinal tract cancers8

Colorectal cancer

Refer adults using a suspected cancer pathway referral (for an appointment within 2 weeks)
for colorectal cancer if:

they are aged 40 and over with unexplained weight loss and abdominal pain or

they are aged 50 and over with unexplained rectal bleeding or

they are aged 60 and over with:

iron-deficiency anaemia or

changes in their bowel habit, or

tests show occult blood in their faeces

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for
colorectal cancer in adults with a rectal or abdominal mass

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Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for
colorectal cancer in adults aged under 50 with rectal bleeding and any of the following
unexplained symptoms or findings:

abdominal pain

change in bowel habit

weight loss

iron-deficiency anaemia

Offer testing with quantitative faecal immunochemical tests (see the NICE diagnostics
guidance on quantitative faecal immunochemical tests to guide referral for colorectal cancer
in primary care) to assess for colorectal cancer in adults without rectal bleeding who:

are aged 50 and over with unexplained:

abdominal pain or

weight loss, or

are aged under 60 with:

changes in their bowel habit or

iron-deficiency anaemia, or

are aged 60 and over and have anaemia even in the absence of iron deficiency.

Anal cancer

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for anal
cancer in people with an unexplained anal mass or unexplained anal ulceration.

© NICE 2021. Suspected cancer: recognition and referral. Available from: www.nice.org.uk/guidance/ng12 All rights
reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE
guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of
its content in this product/publication. See www.nice.org.uk/re-using-our-content/uk-open-content-licence for further
details.

3. Support the diagnosis with appropriate tests

As IBD has an underlying inflammatory process, a full blood count and erythrocyte sedimentation rate
or C-reactive protein are the key blood tests to request, but be aware that normal values do not

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necessarily exclude IBD.4,10 A long history of symptoms (more than 4–6 weeks) usually excludes an
infective cause, but it is sometimes worth sending a sample for stool culture.

It is also worth testing for coeliac disease as this is underdiagnosed and may co-exist with other
gastrointestinal conditions.11 Remember that patients should eat eat some gluten in more than one
meal every day for at least 6 weeks before testing, but this should not delay other investigations.11
Thyroid function tests are not routinely recommended for the investigation of gastrointestinal
symptoms unless the patient has other symptoms that warrant them.10

A patient with a history of gastrointestinal symptoms, evidence of anaemia and/or inflammation on

blood tests, and who does not meet suspected cancer criteria should be referred urgently to a
gastroenterologist.12

4. Appreciate the role of faecal calprotectin

Faecal calprotectin is a calcium-binding protein released by neutrophils in response to inflammation.
The level of this protein in faeces correlates with levels of inflammation.13 Although calprotectin isn’t
a diagnostic test, low levels suggest that the likelihood of underlying pathology is small and this can
be used to give a provisional diagnosis of IBS.10,13 High levels (over 250 mcg/g) of faecal calprotectin
are suggestive of IBD and, as such, should prompt an urgent referral to gastroenterology.4,13 Note
that high levels can also occur in patients with colorectal cancer, and regular use of non-steroidal
anti-inflammatory drugs can sometimes raise levels.13,14

Low levels can occur in patients who only have upper gastrointestinal disease or those who have
microscopic colitis, and a referral to secondary care may be required if their symptoms fail to respond
to treatment in primary care. If faecal calprotectin results are within the 100–250 mcg/g range,
consider repeat testing or a routine referral.4

5. Consider FIT testing if colorectal cancer is suspected

Faecal immunochemical testing (FIT) detects the presence of human haemoglobin (Hb) in faeces and
is more specific than faecal occult blood testing (FOBT),15 which has now been phased out across
almost all of the UK. FIT provides a qualitative result. Using a cut-off of 10 mcg Hb/g faeces, it has a
sensitivity and specificity of around 90% for the detection of colorectal cancer but is considerably less
sensitive to serious colorectal disease (high-risk adenomas or IBD). As such, FIT is better used to
exclude colorectal cancer than IBD.16

6. Offer a colonoscopy when required

Even patients diagnosed with ulcerative colitis on sigmoidoscopy should, within the first year, have an
ileocolonoscopy to confirm the diagnosis, as well as the extent and severity of disease. This may offer
a more definitive diagnosis of ulcerative colitis versus Crohn’s disease, inform predictions of the
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future disease course, and allow risk stratification for dysplasia.4 Patients with microscopic colitis may
be referred via a suspected cancer referral pathway but they may have biopsies taken during their
endoscopy.

Patients who are over 50 years and have been given a diagnosis of IBS but continue to have profuse,
watery, often disabling diarrhoea that doesn’t respond to medical therapies may need to be referred
back for consideration of endoscopy with biopsies, as they may have microscopic colitis.17

7. Provide lifestyle advice and information to patients with confirmed

IBD
Patients with ulcerative colitis taking a maintenance dose of aminosalicylates (5-ASA) should be
encouraged to persist with medication as medium-term evidence suggests that sustained therapy
reduces the risk of flares and colorectal cancer, and the consensus is that this is likely to continue in
the long term.4

Vaccination
Vaccination against influenza and COVID-19 is recommended for all immunosuppressed patients; see
tip 10 for more information on COVID-19 vaccination.18,19 Adults on biologic therapies or significant
immunosuppression, such as oral steroids (more than 40 mg/day prednisolone or equivalent for more
than 1 week, or more than 20 mg/day for more than 14 days), should not have live vaccinations while
they are taking them or for 3 months after stopping, and children born to mothers taking biologic
medication should not receive rotavirus immunisation. See Box 2 for information on the available live
vaccines.20

Box 2: Live vaccines currently available in the UK20

Live influenza vaccine

Measles, mumps, and rubella vaccine

Rotavirus vaccine

Shingles vaccine

BCG vaccine

Oral typhoid vaccine (Ty21a)

Varicella vaccine

Yellow fever vaccine

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BCG=Bacillus Calmette–Guérin

Diet
Some patients find that certain foods trigger their functional symptoms but there is currently no clear
evidence that one group of foods can cause a flare.4 Input from a dietitian is recommended for
patients with multiple food intolerances and those who have been left with a short gut after surgery.4

Contraception
Oral contraception is classed as UK Medical Eligibility Criteria (UKMEC) Category 2 as there may be
significant malabsorption in some patients with IBD.21,22 Effective contraception is particularly
necessary for those taking methotrexate.23 For further information on methods of contraception for
patients with IBD, refer to guidance from the Faculty of Sexual & Reproductive Healthcare.22

Exercise
Regular physical activity is important to help counter the increased risk of low bone mineral density
and osteoporosis from IBD, and many patients report that it helps with their fatigue and reduces
other symptoms of IBD.24

Mental health
Fatigue, anxiety, and depression are common in patients with IBD, partly because of the
neurophysiological effect of chronic inflammation, but also from dealing with the impact of being
diagnosed with a long-term condition at what may be a relatively young age.25 Patients should be
signposted to Crohn’s & Colitis UK for information and support on all aspects of living with IBD.
Formal psychological support may also be helpful.

8. Know how to support patients experiencing a flare

Many patients with IBD also have IBS-type functional symptoms, so it is important to listen to the
patient and to obtain an objective assessment of inflammation where possible, for example, by using
blood tests or a faecal calprotectin test. Note that in some areas, faecal calprotectin testing may be
limited to patients aged under 40 years, and it may take 2 weeks or longer to get a result, so this may
not always be appropriate.

Any patient who is acutely unwell or at risk of sepsis, acute kidney injury, or cardiovascular
compromise due to anaemia needs same-day hospital assessment. Some patients may have a care
plan or flare plan12 so it is wise to be guided by such plans if they are in place, but there are other
local and national flare pathways available.26 It is also important that the patient’s IBD team is
informed whenever oral steroids are used, as more than two courses of oral steroids in a 12-month
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period should trigger a review of the patient’s other medication. Bearing in mind the risk of side-
effects with prolonged use, if patients are refractory to corticosteroids (requiring a repeat course
within 3 months or continuous use for longer than 3 months) alternative treatments should be
considered.4,27

9. Recognise the link between IBD and colorectal cancer

Patients with IBD have an increased risk of colorectal cancer, and this depends upon the length of
time since diagnosis, the amount of bowel affected, and the extent of inflammation.4,28 All patients
with IBD should have their risk assessed at their initial colonoscopy and a timetable established for
screening colonoscopies to start 10 years after diagnosis,28 although the British Society of
Gastroenterology (BSG) recommends starting 8 years after diagnosis.4

Compliance with certain medications, including mesalazine and thiopurines, can reduce the risk of
developing colorectal cancer. However, all patients should be reminded of red flags to look out for if
their symptoms change.4

10. Most patients with IBD should be vaccinated against COVID-19

Many patients with IBD are taking immunosuppressive medication that puts them in the clinically
vulnerable category (Joint Committee for Vaccination and Immunisation [JCVI] priority group six) for
COVID-19 vaccination prioritisation.19 Some will be clinically extremely vulnerable (JCVI priority
group four).29 This depends upon the number and type of medications that they are taking and their
underlying disease activity. The BSG has produced a stratification grid to help clinicians and patients
identify their risk category.30 A Crohn’s & Colitis UK survey found that one in five people with IBD did
not receive the correct shielding information during the first wave of the COVID-19 pandemic,31 so
GPs should ensure their patients with IBD are categorised appropriately in line with the BSG IBD risk
grid.30 All immunosuppressed individuals should have a seasonal influenza vaccination too.18

Dr Kevin Barrett

GP Partner, Rickmansworth

Chair of the Primary Care Society for Gastroenterology

Key points
IBD is a chronic relapsing-remitting, life-long inflammatory condition

Inform diagnosis with blood tests (FBC, ESR, CRP) to identify markers of inflammatory disease

Faecal calprotectin testing can help rule out non-inflammatory conditions

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A FIT result below 10 mcg Hb/g faeces can help exclude colorectal cancer

Lifestyle advice and compliance with medication are important elements for primary care to
manage

IBD can co-exist with other gastrointestinal conditions such as IBS and coeliac disease, and
patients are at increased risk of colorectal cancer

Depending on their situation, patients with IBD may be clinically vulnerable and a priority for
vaccination against influenza and COVID-19.

IBD=inflammatory bowel disease; FBC=full blood count; ESR=erythrocyte sedimentation rate; CRP=C-reactive protein;
FIT=faecal immunochemical testing; Hb=haemoglobin; IBS=irritable bowel syndrome

Implementation actions for clinical pharmacists in general practice

written by Shailen Rao, Managing Director, Soar Beyond Ltd

The following implementation actions are designed to support clinical pharmacists in general
practice with implementing the guidance at a practice level.

Medicines optimisation for patients on long-term medication is a central role for clinical
pharmacists. The mainstay of treatment for IBD is pharmacological treatment and people with
IBD will often have complex treatment regimens, requiring stepping up or down of treatment and
periodic courses of flare management.

Pharmacists are already considered a vital part of the multidisciplinary team within specialist IBD
services. A major part of the pharmacists’ role in optimisation will remain with the secondary care
team, however, clinical pharmacists in general practice have an important role in the care
pathway for patients alongside their clinical colleagues in primary and secondary care.

Support medicines optimisation by:

helping patients to increase their adherence to treatment

assisting with flare management

offering associated medicines to manage symptoms e.g. OTC treatments and pain
management

checking whether a patient’s current therapy is still effective and referring them to
specialists if changes might be necessary

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manage IBD patients taking oral contraception.

Prevent  complications by:

optimising uptake of flu and COVID-19 vaccinations and general advice on vaccinations
for specific groups, e.g. infants born to others taking biologics

encouraging smoking cessation

helping to manage the increased risk of osteoporosis.

There are a plethora of unmet needs that contribute to poor patient experience and outcomes,
adding to the economic burden on the health system. Clinical pharmacists in general practice are
well placed to take a proactive role as part of their day-to-day job to help address these unmet
needs.

IBD=inflammatory bowel disease; OTC=over-the-counter

Guidelines Learning

After reading this article, ‘Test and reflect’ on your updated knowledge with our
multiple-choice questions. We estimate that this activity will take you 30 minutes—
worth 0.5 CPD credits.

References 

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