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

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Dr Kevin Barrett

  • 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.

Read this article online at: GinP.co.uk/455955.article

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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

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
  • 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 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 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

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 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

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
  • 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
    • 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

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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

  1. NICE. Crohn’s disease: what is it? NICE Clinical Knowledge Summary. cks.nice.org.uk/topics/crohns-disease/background-information/definition (accessed 12 March 2021).
  2. NICE. Ulcerative colitis: what are the extra-intestinal manifestations. NICE Clinical Knowledge Summary. cks.nice.org.uk/topics/ulcerative-colitis/background-information/extra-intestinal-manifestations (accessed 12 March 2021).
  3. Pasvol T, Horsfall L, Bloom S et al. Incidence and prevalence of inflammatory bowel disease in UK primary care: A population-based cohort study. BMJ 2020; 10 (7): 36584.
  4. Lamb C, Kennedy N, Raine T et al. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut 2019; 68: s1–s106.
  5. Barrett K. Microscopic colitis: a guide for general practice. Br J Gen Pract 2021; 71 (702): 41–42.
  6. Hellström P, Benno P. The Rome IV: Irritable bowel syndrome–a functional disorder. Best Pract Res Clin Gastroenterol 2019; 40–41: 101634.
  7. NICE. Diarrhoea—adult’s assessment: Scenario: chronic diarrhoea (>4 weeks). NICE Clinical Knowledge Summary. cks.nice.org.uk/topics/diarrhoea-adults-assessment/management/chronic-diarrhoea-more-than-4-weeks (accessed 12 March 2021). 
  8. NICE. Suspected cancer: recognition and referral. NICE Guideline 12. NICE, 2015 (last updated 2021). Available at: www.nice.org.uk/ng12
  9. NICE. Inflammatory bowel disease. NICE Quality Standard 81. NICE, 2015. Available at: www.nice.org.uk/qs81
  10. NICE. Irritable bowel syndrome in adults: diagnosis and management. Clinical Guideline 61. NICE, 2008 (last updated 2017). Available at: www.nice.org.uk/CG61
  11. NICE. Coeliac disease: recognition, assessment and management. NICE Guideline 20. NICE, 2015. Available at: www.nice.org.uk/ng20
  12. IBD UK. IBD standards. ibduk.org/ibd-standards (accessed 12 March 2021). 
  13. NICE. Faecal calprotectin diagnostic tests for inflammatory diseases of the bowel. Diagnostics Guidance 11. NICE, 2013. Available at: www.nice.org.uk/DG11
  14. Tibble J, Sigthorsson G, Foster R et al. High prevalence of NSAID enteropathy as shown by a simple faecal test. Gut 1999; 45: 362–366. 
  15. NICE. Quantitative faecal immunochemical tests to guide referral for colorectal cancer in primary care. Diagnostics Guidance 30. NICE, 2017. Available at: www.nice.org.uk/dg30
  16. Nicholson B, James T, Paddon M et al. Faecal immunochemical testing for adults with symptoms of colorectal cancer attending English primary care: a retrospective cohort study of 14,487 consecutive test requests. Aliment Pharmacol Ther 2020; 52 (6): 1031–1041.
  17. Barrett K. Microscopic colitis: a guide for general practice. Br J Gen Pract 2021; 71 (702): 41–42.
  18. Public Health England. Influenza: the green book, chapter 19. PHE, October 2020. Available at: www.gov.uk/government/publications/influenza-the-green-book-chapter-19 (accessed 12 March 2021).
  19. Public Health England. COVID-19: the green book, chapter 14a. Updated February 2021. Available at: www.gov.uk/government/publications/covid-19-the-green-book-chapter-14a (accessed 12 March 2021).
  20. Public Health England. Contraindications and special considerations, the green book, chapter 6. Updated 26 October 2017. Available at: www.gov.uk/government/publications/contraindications-and-special-considerations-the-green-book-chapter-6 (accessed 12 March 2021).
  21. Faculty of Sexual & Reproductive Healthcare. UK Medical Eligibility Criteria for contraceptive use—UKMEC, 2016 (amended September 2019). FSRH, 2019. Available at: www.fsrh.org/standards-and-guidance/documents/ukmec-2016/
  22. The Faculty of Sexual & Reproductive Healthcare. Sexual and reproductive health for individuals with inflammatory bowel disease. FSRH, 2016. Available at: www.fsrh.org/standards-and-guidance/documents/ceu-clinical-guidance-srh-ibd/
  23. British National Formulary. Methotrexate. Available at: bnf.nice.org.uk/drug/methotrexate.html (accessed 12 March 2021).
  24. Bottoms L, Leighton D, Carpenter R et al. Affective and enjoyment responses to 12 weeks of high intensity interval training and moderate continuous training in adults with Crohn’s disease. PLoS One 2019; 14 (9): e0222060.
  25. Crohn’s and Colitis UK. Fatigue & IBD. www.crohnsandcolitis.org.uk/about-crohns-and-colitis/publications/fatigue-ibd (accessed 12 March 2021).
  26. Royal College of General Practitioners. Inflammatory bowel disease toolkit. Available at: www.rcgp.org.uk/ibd (accessed 12 March 2021).
  27. Barrett K, Saxena S, Pollok R. Using corticosteroids appropriately in inflammatory bowel disease: a guide for primary care. Br J Gen Pract 2018; 68 (675): 497–498.
  28. NICE. Colorectal cancer prevention: colonoscopic surveillance in adults with ulcerative colitis, Crohn’s disease or adenomas. Clinical Guideline 118. NICE, 2011. Available at: www.nice.org.uk/cg118
  29. Department of Health and Social Care. Joint Committee on Vaccination and Immunisation: advice on priority groups for COVID-19 vaccination, 30 December 2020. Updated 6 January 2021. Available at: www.gov.uk/government/publications/priority-groups-for-coronavirus-covid-19-vaccination-advice-from-the-jcvi-30-december-2020/joint-committee-on-vaccination-and-immunisation-advice-on-priority-groups-for-covid-19-vaccination-30-december-2020
  30. British Society of Gastroenterology. BSG expanded consensus advice for the management of IBD during the COVID-19 pandemic. BSG, March 2020 (updated March 2021). Available at: www.bsg.org.uk/covid-19-advice/bsg-advice-for-management-of-inflammatory-bowel-diseases-during-the-covid-19-pandemic/ (accessed 12 March 2021).
  31. Crohn’s and Colitis UK. Life in lockdown: what patients told us about their healthcare. www.crohnsandcolitis.org.uk/healthcare-professionals/healthcare-professionals-blog/life-in-lockdown-what-patients-told-us-about-their-healthcare (accessed 12 March 2021).