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In our seventh episode of the Poo & A series, GP, Paresh Dawda and IBD clinician and researcher

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Dr Aviv Pudipeddi will discuss relapse for people with IBD.

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Join Paresh and Aviv as they look at treating the whole person's mental, physical and social

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health and ways to prevent and treat relapse.

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My name is Aviv, I'm a gastroenterologist working at Concord Hospital and Sydney Adventist

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Hospital, currently in the final stages of completing a PhD, looking at some of our

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medications in inflammatory bowel disease and I'm a clinical lecturer with the University

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of Sydney.

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Thank you.

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So I'm Paresh, I'm a GP based in Canberra, also have a couple of academic affiliations

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with the University of Canberra and UNSW as well and then I do various pieces of advisory

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work with the UNSW Agency for Clinical Innovation and UNSW e-Health, Editor-in-Chief of PMJ's

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Integrated Health Kit.

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This is of course about managing complex patients and relapse and comorbidity in people with

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inflammatory bowel disease.

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We really want to look at that importance of identifying and managing relapses.

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We want to think about other medications patients may use, particularly illicit drugs and how

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that adds to complexity and how we can look at managing that.

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Finally we want to be looking at the psychosocial needs of patients with inflammatory bowel

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disease.

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We had three patients, we had Emma and you may recall we previously met her, she was

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diagnosed with ulcerative colitis in her teens.

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She's now 33 years old, happily married and has a four year old daughter.

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Emma comes to you, to your GP clinic complaining of bloating, diarrhoea, abdominal pain and

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cramping, an urgency to defecate and she's quite lethargic.

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She recently had a flu vaccination and she's concerned that she might have triggered a

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flare of her ulcerative colitis and she's come to you seeking some advice about what

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the next step is.

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So you appropriately order some investigations.

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So you've got some blood test results there, her C-reactive protein is normal, her full

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blood count and liver function tests are normal.

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She's undergone some stool testing confirming that she does have watery bowel motions but

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there's no blood, no evidence of white cells and her testing really has come back negative

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from a culture point of view.

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So Paresh I might ask you, if Emma was coming to see you with these symptoms and you've

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done those investigations, what's your suspicion and clinical decision based on these results?

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Yeah, thanks Aviv.

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So look, obviously a lot of these symptoms are non-specific and so I think she's right

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to have a level of concern around a flare and a colitis being triggered.

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I have to say on the basis of the pathology results, things are really reassuring and

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maybe this isn't a flare up of inflammatory bowel disease, maybe it's another coincidental

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condition, maybe she's got gastroenteritis.

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I would be perhaps thinking about having a conversation with her around what the results

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show, what to do and how to manage that and the safety netting around what to do if her

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symptoms don't settle down.

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Yeah, fantastic, I agree.

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Certainly these testing thus far is quite reassuring.

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Some things I like to do is to use a fecal calprotectin as a nice non-invasive way of

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thinking about whether there could be any inflammation within the bowel.

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So just having a look, if you've got a copy of the last colonoscopy result, if it was

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quite recent and it looked like she was in remission, the likelihood of a flare so quickly

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after a colonoscopy that showed remission is less likely.

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So there's a few different tools that you could consider thinking about to use to sort

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of gauge your level of concern and having a discussion with the treating gastroenterologist

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as well if there were any concerns, absolutely.

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But based on these testing, I agree, it's all reassuring thus far.

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We might move on to Fred.

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So Fred, you might recall an elderly gentleman with comorbidities, so cardiovascular disease,

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diabetes and chronic kidney disease and he's come to you with a number of symptoms including

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rectal pain, he's got abdominal cramping, he's found blood in his stool motions together

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with intermittent diarrhea.

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He's getting some element of incontinence and he's losing weight, he's lost six kilograms

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in the last three months.

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So Paresh, if Fred came to you with these symptoms, what clinical decision would you

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make based on his presentation and how would you go about referring him on from here?

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Thanks, Aviv.

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I think Fred's got some alarming symptoms with the weight loss, with the blood in the

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stool, could be a flare up of this inflammatory bowel disease.

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So given his age and sort of comorbidities, I'd also be concerned about other diagnoses

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such as carcinoma and the cancer.

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So we'd really want to get on top of this quickly and get some investigations early.

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There's a number of ways we could look at this.

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I think he needs specialist opinion quickly really and so it would be a matter of calling

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the gastroenterologist, having a discussion and a dialogue and seeing how quickly we can

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get them in to see one of your colleagues really.

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If he was really, really unwell, you know, might consider even sending him to the emergency

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department.

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It's that responsive, speedy investigation is what we are after here.

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Absolutely, I agree.

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I mean, he certainly does have alarm symptoms in an elderly gentleman, lots of potential

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diagnoses and it really comes down to, you know, we're more than happy for GPs to pick

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up the phone, give us a call and we can gauge how quickly we can see them or get them into

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some form of investigations.

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And if there are concerns about delay and particularly with his medical status, absolutely,

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potentially sending him into the emergency department of your closest hospital.

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I really think it comes down to investigations, starting off with pathology, imaging, colonoscopy

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really and then depending upon what's going on, you could really then dictate therapy

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from there.

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I think it's a bit hard to treat anything without knowing what's going on at this stage.

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Would you agree with that, Paresh?

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Yeah, absolutely.

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I don't think we can do any definitive treatment until we know what's going on.

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If he was in a large degree of pain, then we may think about some symptomatic treatment

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and management pending further investigations, but certainly nothing definitive.

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Perfect.

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So Daniel, he presents to you with diarrhoea.

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His opening is about six times a day.

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He's febrile with a temperature of 39.2, nausea, vomiting, he's dehydrated and lethargic.

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He complains of abdominal pain with cramps.

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He's also developed mouth ulcers.

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He's got blood in his stools and he's lost a significant amount of weight.

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And this is a patient who's got a known history of nonadherence and he's had repeated emergency

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department presentations.

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So Paresh, if he came to you with these symptoms, what clinical decision would you be thinking

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about and what would you do going on from here?

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Yeah, thank you in the context of what we know about the nonadherence, repeated ED presentations

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and the mix of symptoms he presents with.

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I'd be really concerned about a flare up here of his inflammatory bowel disease.

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And what we really want to be doing is working with Daniel to try and engage him with the

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service and keep him engaged, as well as getting on top of his current relapse very quickly

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and the shape that takes may vary depending on the conversation with Daniel.

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It may range from myself trying to treat the flare up in consultation with the gastroenterologist

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and doing that whilst Daniel's in the room because we know the risk of him coming back

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is low.

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So act on it quickly whilst he's on the room, get some advice if I needed it and try and

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get on top of it and then I think trying to get that proactive follow up happening and

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put in place ways of reminding him to turn up for his future appointment and really try

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and get him re-engaged with services.

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I agree, I agree.

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I mean, certainly he does warrant urgent investigations, but as you said, we've got to take into account

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his history of nonadherence and working with him and ensuring that element of rapport is

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there with Daniel.

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Fantastic.

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So I guess when we think about inflammatory bowel disease and the form of relapse, people

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can have varying symptoms from time to time and that might be suggestive of a mild to

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severe disease phenotype with a flare, but we've got to remember that symptoms that people

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have may not always correlate with what's actually happening within the bowel.

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So some people may not have many symptoms, but there could be a significant inflammation

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when you do objective testing and vice versa.

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Some people may have a variety of different gut symptoms that may not be reflective of

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disease inflammation.

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And that's where using objective markers is really important, whether that's in the form

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of blood tests such as a C-reactive protein or using a fecal calprotectin where possible,

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I think is a nice noninvasive way of really demonstrating whether there is any inflammation

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or not.

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And these markers, the CRP and in particular the calprotectin is quite a useful predictor

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for clinical relapse and disease progression, so certainly something that I encourage GPs

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to use when required.

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As I said, please do pick up the phone to your friendly gastroenterologist, give them

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a call, see if they can be seen quickly or if you have access to a specialist IBD centre,

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that's another avenue as well to think about.

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Making sure you're engaging patients in the whole process, making them aware of what your

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plans are and having that element of shared care planning is really important.

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Alright, so turning our attention to this concept of the known and the unknown, which

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really some patients who use illicit drugs are complementary and alternative medications

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and how we sort of manage that in the consultation room.

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So we'll turn back to Daniel.

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During Daniel's time in the practice, the practice nurse strikes rapport, he's got a

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gentle and encouraging conversation with him and he mentions that he's been struggling

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with anxiety, he's not doing well in college, he's wanting to build muscles and was trying

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to keep up with his friends who were going to the gym quite a lot.

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You got to recall a lot of our patients are young adults and they've got these other coexisting

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elements of their lifestyle that they want to try and meet.

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And look, the doctor now suspects that the high protein meals probably contributed to

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an active disease and flare.

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Also Daniel mentions to the nurse that he and his friends go out partying on weekends

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and he's starting to use illicit drugs, typically marijuana, and he has experimented with other

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party drugs to help his anxiety.

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So Parash, I might ask you, if Daniel came to you with these different issues, how would

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you structure your conversation and investigate his use of high protein foods and illicit

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drugs?

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So we want to maintain this rapport with Daniel and not put him off by being too questioning

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or appearing judgmental.

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I think the approach is really around taking a very open sort of dialogic conversational

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approach to this and gently prodding to see how much information he's willing to give

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and share.

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And I think for me, my priority at this stage would be about engaging with him, connecting

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with him, making sure he feels comfortable enough to come back, see me and talk to me.

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And then just that gentle inquiry around some of his behaviors.

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Yeah, absolutely.

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I agree.

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I think the number one issue is to try and ensure you've established that element of

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rapport and not being judgmental and trying to include as much as possible into the conversation

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about how you take things further.

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Absolutely.

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When we look at diets and the different sort of weight management approaches, people with

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inflammatory bowel disease can have consequences of undernutrition, but also overnutrition.

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I think that balance as supportive diets can really help symptom management.

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So it's certainly something we should be encouraging.

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Disadvantages, exclusive end to nutrition, that's a multidisciplinary sort of guided

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decision that teams will often take.

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We talked broader earlier around sort of mental health issues.

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And I think, again, disordered eating and issues in relation to that and the comorbidity

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with inflammatory bowel disease is increasingly recognized and perhaps a bit of an emerging

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issue.

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When we think about illicit drugs and inflammatory bowel disease, it's an increasing problem

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and it's something we need to be aware of.

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That illicit drug use seems to be more of an issue in younger patients, may be associated

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with comorbidities around mental health.

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But, you know, I don't think it's exclusive to that group.

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I think certainly in primary care as GPs, we need to sort of normalize and create that

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safe space for people to have conversations with us around the other things with illicit

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drugs.

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If patients feel like they can't talk to us, they won't tell us.

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But that activity still carries on, right?

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Sometimes patients will use illicit drugs either to suppress the symptoms or for pain

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management.

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So it may be that it's under treatment that's leading to some sort of illicit use.

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The two are obviously deeply interconnected.

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When we're thinking about anxiety and mental health, you know, there's high rates in people

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with inflammatory bowel disease, just as there are in people with any chronic disease.

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You know, we see higher rates of anxiety and depression.

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And we came to see our practice nurse, she'd managed to elicit that Daniel was using marijuana's

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open strategy.

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The GP really hadn't addressed the issue of why.

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Daniel's now left college and is no longer able to access a counselor at college.

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His GP suspects he'd benefit from psychological services.

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We could ask Daniel to see how he's managing, to see how he's coping, really to maneuver

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that conversation in a constructive and a healthy way.

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And in my experience, I think it's, you know, examples of good questions are those open

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questions, you know, simple things like how are things going, Daniel, giving him opportunities

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and space to talk, you know, what are you up to now?

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You left school, college, it's another example.

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Is there anything you're missing about school?

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That might be the response around the school counselor not being there.

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What is he looking forward to?

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What are his career aspirations?

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What's stopping him from achieving that?

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How are you feeling about your condition?

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Do you feel in control?

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Do you feel in control of your emotions?

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So those sorts of open questions, exploratory inquiry type of questions, I think can help

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us really understand the context of the person, particularly in relation to their mental health.

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And you know, the stats speak for themselves, don't they?

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So a third of patients with chronic bowel disease is likely to have a mental health

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condition at any given time.

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It doesn't matter whether it's ulcerative colitis or Crohn's disease.

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And we know that when people present with the flera, that percentage doubles, it goes

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up to 66%.

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So it has a big impact on flares.

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When we look at a younger cohort of patients, the rates are higher and we, you know, we're

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often not diagnosed.

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So it's being unrecognized.

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And we know from research which demonstrates that that increase risk of depression is up

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to 25%.

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And that leads to worse adherence and therefore treatment outcomes in young people with inflammatory

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bowel disease.

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I think as GPs, we probably play a really critical central role in the early identification,

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diagnosis and management of psychological comorbidity in people with inflammatory bowel

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disease.

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And, you know, we don't have to manage it all ourselves, including psychologists, dieticians

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as members of that inflammatory bowel disease management team, together with the gastroenterologists,

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et cetera, as part of multidisciplinary care team.

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I think when we look at young people, what we really want to be focusing in on is building

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their health literacy, their knowledge, skills, their confidence to start to engage in looking

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after their own health.

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We certainly see it a lot of the time for our patients because end of the day, the medications

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that we do use, a lot of them are designed to suppress the immune system and do have

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potential side effects.

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So it's really firstly, as we've discussed, being open, non-judgmental and trying to explore

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that anxiety and try and find out exactly which side effects they're particularly concerned

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by.

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For some people, if they've got good health literacy, discussing some of the evidence,

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some of the data regarding those side effects and the relatively uncommon nature in which

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a lot of them do occur.

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And then also trying to marry that up with their current gut symptoms and the inflammation

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and trying to have that discussion about benefits and risks.

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And I guess some of the risks of not treating with effective medical management comes into

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play.

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So I think you need to set time for this.

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It's certainly a conversation that I don't like to rush through and I want to explore

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the patient's feelings as much as possible and try and work with them to try and overcome

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some of that anxiety as best as possible.

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So I think it's for patients who do have that coexisting mental health concerns, for people

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who do have access or do see a psychologist, certainly involving them where possible, I

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think it's really important.

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And trying to bring in that multidisciplinary aspect of IBD care to assist with that anxiety

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because it's all well and good for us as gastroenterologists to say, here, take this, you'll be great.

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But on the flip side, if you're a patient, I'm sure many of them, as we've seen, do

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have concerns and is trying to get into their shoes and trying to help them through that

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journey when it comes to some of the medications that we use.

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Thank you.

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This podcast series is produced by Agpal as part of a consortium with Crohn's and Colitis

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Australia and the Gastroenterological Society of Australia as part of an Australian Government

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grant.

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This is the seventh episode in our first series of Poo and A.

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For more resources, including a suite of e-learning modules and live e-workshops, head to the

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Crohn's and Colitis Australia GutSmart website.

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Follow the link in the podcast description.

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We support GPs in diagnosing and treating IBD and assist patients to get the support

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they need from a gastroenterologist to live their best lives with the significant lifelong

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condition.

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