Features

Time to digest

12 January 2018

Digestive disorders are more of an issue than we like to admit, and can also be confusing. So how can you help families tell IBD from IBS, and when’s the right time to see a GP? Journalist John Windell reports.

Digestive tract

Digestive disorders are among the most common health problems, but also one of those we least like talking about.

While estimates suggest that GPs spend around 10% of their time dealing with patients who have digestive disorders (Jones et al, 2009), this may be far from the full picture: as many as 43% of the people in the UK (a representative sample of 2287 adults) say they have experienced a digestive problem, but up to 41% of those have never made an appointment with their GPs to discuss it (YouGov and Core, 2010). While many of those who stay away from their surgery say it’s because they managed or resolved the symptoms themselves, 18% of those with a problem didn’t think a GP could help, and 5% just didn’t want to talk to anyone about their bowels (YouGov and Core, 2010).

Individually, symptoms such as abdominal pain and discomfort, diarrhoea, bloating, flatulence and constipation may not indicate much more than a passing issue that clears up on its own. But if they persist or combine with each other, they could indicate a digestive disorder, and in that case, will require a visit to the GP.

Digestive disorders divide into two broad categories. The first is inflammatory bowel disease (IBD), which consists largely of just two key conditions, Crohn’s disease and ulcerative colitis. According to the charity Crohn’s & Colitis UK, these diseases affect more than 300,000 people in the UK.

The second category is irritable bowel syndrome (IBS), which is more a collection of symptoms than a definable disease, but it can add up to a chronic and debilitating long-term condition. According to the charity Core, IBS may affect up to a third of the population to some degree.

Digestive problems statistics

 

Crohn’s disease

This is a lifelong condition that can develop at any time. It manifests as an inflammation of the lining of the digestive system, anywhere from the mouth to the anus, but most usually in the small or large intestine, leading to malabsorption, scarring and constrictions. The cause is unclear, though it’s suspected it may be linked to the immune system and to the genes.

The main symptoms are persistent diarrhoea, sometimes with blood and mucus in the stools, stomach and abdominal cramps, severe fatigue, weight loss, anaemia and mouth ulcers. These symptoms can occur individually or all at once. They can also go into remission for long periods, then suddenly flare up. There is no cure, but it can be managed with medication, such as steroids and immunosuppressants. In severe cases, surgery might be needed to repair or even remove parts of the intenstine.

Dr Kevin Barrett, a GP at a practice near Watford, has Crohn’s disease and is leading the RCGP’s spotlight project on IBD. His key advice to community practitioners is: ‘Be aware of persistent symptoms that don’t go away. Anybody who has these symptoms or changing bowel habits for more than four weeks should see their GP. The symptoms can also overlap with other diseases, particularly in older people and women. Bowel cancer is one, so is ovarian cancer and endometriosis.’

 

Intestines xray

 

Ulcerative colitis

This is also a long-term incurable condition, the difference being, it inflames the colon and the rectum, often leading to small ulcers that bleed. Again the cause is uncertain, though ulcerative colitis has also been linked to problems with the immune system and may be hereditary.

The symptoms of colitis are similar to Crohn’s, so diarrhoea, abdominal cramps and pain, tiredness, reduced appetite, weight loss and anaemia. Ulcerative colitis affects around 146,000 people and can affect anyone, but most often appears between the ages of 15 and 25, say Crohn’s & Colitis UK.

As the two diseases are so alike, the same blood tests and faecal calprotectin test are used during the initial investigation. The only real way to tell them apart is with a colonoscopy and biopsy. Treatments for the two are broadly interchangeable as well. So for colitis it’s also medication, and surgery in the most severe cases.

For Dr Barrett, the early onset of ulcerative colitis can present other issues. ‘If you are in your 20s you are probably in education, or starting a job or family, so to be diagnosed with a lifelong relapsing condition can be a blow. People can need support not just with treatment and diet, but also employment rights, financing and counselling.’

On a more positive note, research into IBD is widening to look at the potential of probiotics and fecal transplants. The early signs are encouraging, says Dr Barrett. ‘The role of good bacteria in the guts is coming to the fore in IBD treatment.’

 

Irritable bowel syndrome

IBS is defined by a series of uncomfortable and painful symptoms. These include stomach and abdominal cramps, bloating and colic, diarrhoea, sometimes with mucus in the stools, or constipation. People with IBS may also feel tired. The symptoms will vary between individuals, and may come and go.

IBS is more prevalent among the 20 to 40 age group and women, say charity Core. The cause is uncertain, but it has been linked to stress and diet. The key problem appears to be increased sensitivity to movement within the bowel.

Dietitian Priya Tew says she sees a lot of people with IBS: ‘I think it is often related to stress. The people I see tend to have busy lifestyles, and often don’t sit down and take time over their meals. They inhale their food. I’ve also seen it in people who have chronic fatigue.’

So treatment for IBS often begins by looking at an individual’s lifestyle and diet. ‘I start with stress management, relaxation and exercise,’ says Priya. ‘Then it’s how and where they are eating their meals. I would offer different advice depending on whether somebody has diarrhoea-prominent or constipation-prominent IBS. For example, with the diarrhoea form I might get them to reduce their soluble fibre, but if they have constipation I might ask them to increase their fibre.’

For anyone with IBS, it’s key that they identify and then avoid the foods that trigger their symptoms. Plenty of over-the-counter medicines are also available – GPs or pharmacists can provide advice. Cognitive behavioural therapy and even antidepressants may be prescribed in severe cases. Some people also turn to alternative therapies, such as acupuncture and aromatherapy, though there is little evidence they work.

If symptoms are persistent, a trip to the GP is advised, especially as they could also signify coeliac disease. This is where the immune system reacts to gluten, a protein found in wheat and other grains, and damages the lining of the small intestine. Coeliac UK (2017a) says one in 100 people have the disease, but that nearly half a million people are undiagnosed (2017b).

So for community practitioners, it’s useful to know the signs of the various digestive disorders, and vital to encourage people to see their GPs when those symptoms become stubborn. You can also point people to the various charities, where specialist help is often on hand (see resources, below).


Carrie Grant

 

Carrie talks crohn’s

Broadcaster and honorary president of the CPHVA Carrie Grant talks about her experience of Crohn’s disease, which began at 18.

‘It took two years to get diagnosed. I saw so many doctors, but nobody could tell me anything. Then a dentist saw the ulcers in my mouth and asked if I also had diarrhoea and skin rashes. I did, and he said: “I think I know what the problem is.” It’s a big thing when you’re are 20 to be told you have an incurable disease. It took me five years to adapt. I had surgery, and was in and out of hospital. My whole life was consumed with being a sick person.

‘For me stress is a trigger. I try to be laid back, but I lead a stressful life. I also stick to a limited diet. At the moment I am dairy-free and carb-free. So I eat meat, fish, fruit and vegetables. For others it might be different.

‘Health professionals could be more aware of Crohn’s. It has a clear group of symptoms. The initial investigation is also about listening. It may be, on one visit the person mentions one thing, and adds something next time, so it’s about joining the dots.

‘Community practitioners can help people to filter out the rubbish they see online and help them get to the heart of what they’re struggling with. The great thing about being in someone’s house is you can take a more holistic approach than if just in a GP surgery.’


Resources

  • Core is the national charity for all digestive diseases corecharity.org.uk
  • Crohn’s & Colitis UK is the national charity for IBD crohnsandcolitis.org.uk
  • The IBS Network is the national charity for supporting people with IBS theibsnetwork.org
  • The British Dietetic Association has a factsheet on IBS bit.ly/BDA_IBS
  • Coeliac UK is the national charity for people with the disease coeliac.org.uk
  • NHS Choices covers all the conditions.

 

Picture credits: iStock / Alamy


References

Coeliac UK (2017a). About coeliac disease. See: www.coeliac.org.uk/coeliac-disease/about-coeliac-disease-and-dermatitis-herpetiformis (accessed 6 December 2017).

Coeliac UK (2017b). Is it coeliac disease? See: bit.ly/2ACSrHx (accessed 6 December 2017).

Core (2017). Irritable bowel syndrome. See: bit.ly/2iAWbRM (accessed 5 December 2017).

Crohn’s & Colitis UK (2017). For Journalists. See: crohnsandcolitis.org.uk/news/for-journalists (accessed 5 December 2017).

Crohn’s & Colitis UK (2017). Ulcerative Colitis. See: bit.ly/2CL1dDh (accessed 5 December 2017).

Jones R, Hunt C, Stevens R, Dalrymple J, Driscoll R, Sleet S, Blanchard Smith J. (2009) Management of common gastrointestinal disorders: quality criteria based on patients’ views and practice guidelines. The British Journal of General Practice 59(563): e199-208.

YouGov and Core. (2010) Digesting the facts: what people are thinking about their digestive health. See: http://corecharity.org.uk/wp-content/uploads/2016/08/DigestingTheFactsReport.pdf (accessed 5 December 2017).

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