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

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

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

4. History and basic tests
provide most of the answers

5. 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.

6. 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!

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

8. 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%

9. UC Endoscopic appearances

10. 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.

11. Crohn’s disease – patchy, pleiomorphic ulcers

12. Perianal Crohn’s
Tags
Fistulae
Abscess

13. Features distinguishing IBD vs IBSUC
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

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

15. 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

16. 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

17. 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

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

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

20. 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)

21. 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

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

23. 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

24. 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

25. 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

26. 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.

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