IBD vs IBS diagnosis and management Dr Miles Parkes Consultant Gastroenterologist Addenbrooke’s Hospital, Cambridge Spire Cambridge Lea Hospital

Young patients with abdo symptoms IBD vs IBS Differing aetiologies Symptoms Differentiating features Management Cases

Diagnosing IBD Key differentials (NB each can co-occur in patients with IBD) Functional / IBS / food intolerance Infection Malabsorption Neoplasia Other – ischaemia etc.

History and basic tests provide most of the answers

Functional / irritable bowel syndrome / IBS Key is positive diagnosis based on symptoms + normal baseline tests ‘typical’ = rapidly alternating constipn / diarrhoea but either can predominate bloating - abdo pain eased by BO tiredness - sense of incomplete emptying Commonest in young anxious females +/- assoc GORD, fibromyalgia, depression etc.

Infection Sudden onset diarrhoea +/- blood CRP ↑ ↑ vs UC Assoc vomiting, gripey pain +/- fever CRP ↑ ↑ vs UC Stool microscopy, culture + C Diff toxin NB: Post-infectious IBS can last months / years – often causes confusion!

IBD - inflammatory bowel disease Rel rare – 0.2-0.4% Ulcerative colitis and Crohn’s disease cause unknown - genetic + environmental risks (smoking, NSAIDs, bacteria etc) - immunological up-regulation, TNF etc

What is UC? A relapsing / remitting form of IBD Classic symptoms = bloody diarrhoea with urgency +/- incont colon only involved continuous inflammation from rectum to any extent ‘north’ Langholtz et al Gastro 1994 Can usually be diagnosed in clinic with rigid sigmoidoscope 44% 36% 18%

UC Endoscopic appearances

What is Crohn’s disease? A relapsing / remitting form IBD Patchy, deep ulceration, with tendency to stricture and fistulate commonly ileal, colonic – can be anywhere Symptoms a site involvement abdo pain, wt loss = ileal diarrhoea (non-bloody) - colonic perianal disease – woody tags / abscess / fistulae etc.

Crohn’s disease – patchy, pleiomorphic ulcers

Perianal Crohn’s Tags Fistulae Abscess

Features distinguishing IBD vs IBS UC Urgency / fear incont Nocturnal diarrhoea Bloody stool Just quit smoking CD Pain – esp post-prandial Wt loss (afraid to eat) Both EIMs – mouth ulcers etc FHx IBD IBS Bloating / tenesmus Rapid variation in bowel pattern Bloods normal Sigmoidoscopy: normal mucosa

Non-distinguishing features IBD vs IBS Mucus PR Young > old Association with stress Tiredness ++

Investigation Stool cultures – for acute diarrhoea Sigmoidoscopy +/- rectal biopsy Bloods: esp ESR/CRP (NB mild increase), albumin, FBC Fecal calprotectin If baseline tests indicative / suspicion high / older pt Colonoscopy / ileoscopy + biopsy Small bowel studies: Radiology: Ba studies, MRI, USS, CT Capsule enteroscopy

Management of IBS Confident diagnosis (check bloods ‘to rule out anything else’ – incl CRP and coeliac) Explain and reassure – many need no more Don’t let it interrupt school, life, work etc Diet modification +/- fibre supplements anti-spasmodics, loperamide, tri-cyclics alternatives

Diet in IBS Low fibre diet often helps – may need OTC fibre supplement Can try 10/7 rotating exclusions of most likely culprits: Dairy (NB calcium) Wheat Rich / fatty

Titbits Long term loperamide is safe – even at high doses Long term laxatives also safe if reqd Amitriptyline 10-25 mg nocte only medication shown to help IBS Expect variable symptom pattern over time – intensity and character; titrate Rx accordingly

IBD treatment options Support Diet Drugs Surgery and STOP SMOKING for CD

Mild-moderate UC Mesalazine (5ASA) is main therapy for acute flares and to maintain remission – given Orally Rectally Proctitis => suppositories Recto-sigmoid => foam enema More extensive => liquid enema Or in combination (= most effective)

Drugs: moderate flare IBD Oral corticosteroids: 60-80% respond oral prednisolone: 40mg => 0 / 8 wks But s/e’s accumulate - esp bone loss - For ileal CD - slow release budesonide (Entocort) 9mg -> 6mg -> 3mg od 4-6 wks each, then stop: efficacy approaches pred; expensive If pt requires > 2 courses per yr, or cannot get off steroid => immunomodulatory therapy

Acute Severe UC + Systemic upset  6 bloody stools/24 hrs Fever > 37.5 Tachycardia >90 Truelove and Witts Anaemia Hb < 10.5 criteria ESR > 30 Anorexia, Vomiting Low albumin etc.

Acute Severe UC Investigate confirm diagnosis (esp rule out infection) assess severity and extent of disease identify / predict complications early Admit, rehydrate + restore K+/Na+/nutrition iv steroid – hydrocortisone 100mg qds or methyl prednisone 40mg bd DVT prophylaxis

Long term Immunomodulator and anti-TNF therapy for IBD CD and UC 1st line = Azathioprine or 6 mercaptopurine 2nd line = Methotrexate – weekly, avoid in pregnancy Anti-TNF therapy – infliximab or adalimumab

Immunomodulatory therapy Warn patients re side-effects Monitor bloods – 2 weekly initially, then 3 monthy If fever – stop temporarily pending FBC Can use TDM to work margins Azathioprine and 6MP (not MTX) are safe in pregnancy

When surgery in IBD? Timely surgery 1. where medical therapy is not working in acute or chronic setting do not persevere with failing medical therapy… 2. for complications obstruction due to fibrotic strictures abscess symptomatic fistula megacolon etc.

Conclusions Things are usually what they seem Clinical features and basic investigations provide a reliable guide to diagnosis and management