In our seventh episode of the Poo & A series, GP, Paresh Dawda and IBD clinician and researcher
Dr Aviv Pudipeddi will discuss relapse for people with IBD.
Join Paresh and Aviv as they look at treating the whole person's mental, physical and social
health and ways to prevent and treat relapse.
My name is Aviv, I'm a gastroenterologist working at Concord Hospital and Sydney Adventist
Hospital, currently in the final stages of completing a PhD, looking at some of our
medications in inflammatory bowel disease and I'm a clinical lecturer with the University
of Sydney.
Thank you.
So I'm Paresh, I'm a GP based in Canberra, also have a couple of academic affiliations
with the University of Canberra and UNSW as well and then I do various pieces of advisory
work with the UNSW Agency for Clinical Innovation and UNSW e-Health, Editor-in-Chief of PMJ's
Integrated Health Kit.
This is of course about managing complex patients and relapse and comorbidity in people with
inflammatory bowel disease.
We really want to look at that importance of identifying and managing relapses.
We want to think about other medications patients may use, particularly illicit drugs and how
that adds to complexity and how we can look at managing that.
Finally we want to be looking at the psychosocial needs of patients with inflammatory bowel
disease.
We had three patients, we had Emma and you may recall we previously met her, she was
diagnosed with ulcerative colitis in her teens.
She's now 33 years old, happily married and has a four year old daughter.
Emma comes to you, to your GP clinic complaining of bloating, diarrhoea, abdominal pain and
cramping, an urgency to defecate and she's quite lethargic.
She recently had a flu vaccination and she's concerned that she might have triggered a
flare of her ulcerative colitis and she's come to you seeking some advice about what
the next step is.
So you appropriately order some investigations.
So you've got some blood test results there, her C-reactive protein is normal, her full
blood count and liver function tests are normal.
She's undergone some stool testing confirming that she does have watery bowel motions but
there's no blood, no evidence of white cells and her testing really has come back negative
from a culture point of view.
So Paresh I might ask you, if Emma was coming to see you with these symptoms and you've
done those investigations, what's your suspicion and clinical decision based on these results?
Yeah, thanks Aviv.
So look, obviously a lot of these symptoms are non-specific and so I think she's right
to have a level of concern around a flare and a colitis being triggered.
I have to say on the basis of the pathology results, things are really reassuring and
maybe this isn't a flare up of inflammatory bowel disease, maybe it's another coincidental
condition, maybe she's got gastroenteritis.
I would be perhaps thinking about having a conversation with her around what the results
show, what to do and how to manage that and the safety netting around what to do if her
symptoms don't settle down.
Yeah, fantastic, I agree.
Certainly these testing thus far is quite reassuring.
Some things I like to do is to use a fecal calprotectin as a nice non-invasive way of
thinking about whether there could be any inflammation within the bowel.
So just having a look, if you've got a copy of the last colonoscopy result, if it was
quite recent and it looked like she was in remission, the likelihood of a flare so quickly
after a colonoscopy that showed remission is less likely.
So there's a few different tools that you could consider thinking about to use to sort
of gauge your level of concern and having a discussion with the treating gastroenterologist
as well if there were any concerns, absolutely.
But based on these testing, I agree, it's all reassuring thus far.
We might move on to Fred.
So Fred, you might recall an elderly gentleman with comorbidities, so cardiovascular disease,
diabetes and chronic kidney disease and he's come to you with a number of symptoms including
rectal pain, he's got abdominal cramping, he's found blood in his stool motions together
with intermittent diarrhea.
He's getting some element of incontinence and he's losing weight, he's lost six kilograms
in the last three months.
So Paresh, if Fred came to you with these symptoms, what clinical decision would you
make based on his presentation and how would you go about referring him on from here?
Thanks, Aviv.
I think Fred's got some alarming symptoms with the weight loss, with the blood in the
stool, could be a flare up of this inflammatory bowel disease.
So given his age and sort of comorbidities, I'd also be concerned about other diagnoses
such as carcinoma and the cancer.
So we'd really want to get on top of this quickly and get some investigations early.
There's a number of ways we could look at this.
I think he needs specialist opinion quickly really and so it would be a matter of calling
the gastroenterologist, having a discussion and a dialogue and seeing how quickly we can
get them in to see one of your colleagues really.
If he was really, really unwell, you know, might consider even sending him to the emergency
department.
It's that responsive, speedy investigation is what we are after here.
Absolutely, I agree.
I mean, he certainly does have alarm symptoms in an elderly gentleman, lots of potential
diagnoses and it really comes down to, you know, we're more than happy for GPs to pick
up the phone, give us a call and we can gauge how quickly we can see them or get them into
some form of investigations.
And if there are concerns about delay and particularly with his medical status, absolutely,
potentially sending him into the emergency department of your closest hospital.
I really think it comes down to investigations, starting off with pathology, imaging, colonoscopy
really and then depending upon what's going on, you could really then dictate therapy
from there.
I think it's a bit hard to treat anything without knowing what's going on at this stage.
Would you agree with that, Paresh?
Yeah, absolutely.
I don't think we can do any definitive treatment until we know what's going on.
If he was in a large degree of pain, then we may think about some symptomatic treatment
and management pending further investigations, but certainly nothing definitive.
Perfect.
So Daniel, he presents to you with diarrhoea.
His opening is about six times a day.
He's febrile with a temperature of 39.2, nausea, vomiting, he's dehydrated and lethargic.
He complains of abdominal pain with cramps.
He's also developed mouth ulcers.
He's got blood in his stools and he's lost a significant amount of weight.
And this is a patient who's got a known history of nonadherence and he's had repeated emergency
department presentations.
So Paresh, if he came to you with these symptoms, what clinical decision would you be thinking
about and what would you do going on from here?
Yeah, thank you in the context of what we know about the nonadherence, repeated ED presentations
and the mix of symptoms he presents with.
I'd be really concerned about a flare up here of his inflammatory bowel disease.
And what we really want to be doing is working with Daniel to try and engage him with the
service and keep him engaged, as well as getting on top of his current relapse very quickly
and the shape that takes may vary depending on the conversation with Daniel.
It may range from myself trying to treat the flare up in consultation with the gastroenterologist
and doing that whilst Daniel's in the room because we know the risk of him coming back
is low.
So act on it quickly whilst he's on the room, get some advice if I needed it and try and
get on top of it and then I think trying to get that proactive follow up happening and
put in place ways of reminding him to turn up for his future appointment and really try
and get him re-engaged with services.
I agree, I agree.
I mean, certainly he does warrant urgent investigations, but as you said, we've got to take into account
his history of nonadherence and working with him and ensuring that element of rapport is
there with Daniel.
Fantastic.
So I guess when we think about inflammatory bowel disease and the form of relapse, people
can have varying symptoms from time to time and that might be suggestive of a mild to
severe disease phenotype with a flare, but we've got to remember that symptoms that people
have may not always correlate with what's actually happening within the bowel.
So some people may not have many symptoms, but there could be a significant inflammation
when you do objective testing and vice versa.
Some people may have a variety of different gut symptoms that may not be reflective of
disease inflammation.
And that's where using objective markers is really important, whether that's in the form
of blood tests such as a C-reactive protein or using a fecal calprotectin where possible,
I think is a nice noninvasive way of really demonstrating whether there is any inflammation
or not.
And these markers, the CRP and in particular the calprotectin is quite a useful predictor
for clinical relapse and disease progression, so certainly something that I encourage GPs
to use when required.
As I said, please do pick up the phone to your friendly gastroenterologist, give them
a call, see if they can be seen quickly or if you have access to a specialist IBD centre,
that's another avenue as well to think about.
Making sure you're engaging patients in the whole process, making them aware of what your
plans are and having that element of shared care planning is really important.
Alright, so turning our attention to this concept of the known and the unknown, which
really some patients who use illicit drugs are complementary and alternative medications
and how we sort of manage that in the consultation room.
So we'll turn back to Daniel.
During Daniel's time in the practice, the practice nurse strikes rapport, he's got a
gentle and encouraging conversation with him and he mentions that he's been struggling
with anxiety, he's not doing well in college, he's wanting to build muscles and was trying
to keep up with his friends who were going to the gym quite a lot.
You got to recall a lot of our patients are young adults and they've got these other coexisting
elements of their lifestyle that they want to try and meet.
And look, the doctor now suspects that the high protein meals probably contributed to
an active disease and flare.
Also Daniel mentions to the nurse that he and his friends go out partying on weekends
and he's starting to use illicit drugs, typically marijuana, and he has experimented with other
party drugs to help his anxiety.
So Parash, I might ask you, if Daniel came to you with these different issues, how would
you structure your conversation and investigate his use of high protein foods and illicit
drugs?
So we want to maintain this rapport with Daniel and not put him off by being too questioning
or appearing judgmental.
I think the approach is really around taking a very open sort of dialogic conversational
approach to this and gently prodding to see how much information he's willing to give
and share.
And I think for me, my priority at this stage would be about engaging with him, connecting
with him, making sure he feels comfortable enough to come back, see me and talk to me.
And then just that gentle inquiry around some of his behaviors.
Yeah, absolutely.
I agree.
I think the number one issue is to try and ensure you've established that element of
rapport and not being judgmental and trying to include as much as possible into the conversation
about how you take things further.
Absolutely.
When we look at diets and the different sort of weight management approaches, people with
inflammatory bowel disease can have consequences of undernutrition, but also overnutrition.
I think that balance as supportive diets can really help symptom management.
So it's certainly something we should be encouraging.
Disadvantages, exclusive end to nutrition, that's a multidisciplinary sort of guided
decision that teams will often take.
We talked broader earlier around sort of mental health issues.
And I think, again, disordered eating and issues in relation to that and the comorbidity
with inflammatory bowel disease is increasingly recognized and perhaps a bit of an emerging
issue.
When we think about illicit drugs and inflammatory bowel disease, it's an increasing problem
and it's something we need to be aware of.
That illicit drug use seems to be more of an issue in younger patients, may be associated
with comorbidities around mental health.
But, you know, I don't think it's exclusive to that group.
I think certainly in primary care as GPs, we need to sort of normalize and create that
safe space for people to have conversations with us around the other things with illicit
drugs.
If patients feel like they can't talk to us, they won't tell us.
But that activity still carries on, right?
Sometimes patients will use illicit drugs either to suppress the symptoms or for pain
management.
So it may be that it's under treatment that's leading to some sort of illicit use.
The two are obviously deeply interconnected.
When we're thinking about anxiety and mental health, you know, there's high rates in people
with inflammatory bowel disease, just as there are in people with any chronic disease.
You know, we see higher rates of anxiety and depression.
And we came to see our practice nurse, she'd managed to elicit that Daniel was using marijuana's
open strategy.
The GP really hadn't addressed the issue of why.
Daniel's now left college and is no longer able to access a counselor at college.
His GP suspects he'd benefit from psychological services.
We could ask Daniel to see how he's managing, to see how he's coping, really to maneuver
that conversation in a constructive and a healthy way.
And in my experience, I think it's, you know, examples of good questions are those open
questions, you know, simple things like how are things going, Daniel, giving him opportunities
and space to talk, you know, what are you up to now?
You left school, college, it's another example.
Is there anything you're missing about school?
That might be the response around the school counselor not being there.
What is he looking forward to?
What are his career aspirations?
What's stopping him from achieving that?
How are you feeling about your condition?
Do you feel in control?
Do you feel in control of your emotions?
So those sorts of open questions, exploratory inquiry type of questions, I think can help
us really understand the context of the person, particularly in relation to their mental health.
And you know, the stats speak for themselves, don't they?
So a third of patients with chronic bowel disease is likely to have a mental health
condition at any given time.
It doesn't matter whether it's ulcerative colitis or Crohn's disease.
And we know that when people present with the flera, that percentage doubles, it goes
up to 66%.
So it has a big impact on flares.
When we look at a younger cohort of patients, the rates are higher and we, you know, we're
often not diagnosed.
So it's being unrecognized.
And we know from research which demonstrates that that increase risk of depression is up
to 25%.
And that leads to worse adherence and therefore treatment outcomes in young people with inflammatory
bowel disease.
I think as GPs, we probably play a really critical central role in the early identification,
diagnosis and management of psychological comorbidity in people with inflammatory bowel
disease.
And, you know, we don't have to manage it all ourselves, including psychologists, dieticians
as members of that inflammatory bowel disease management team, together with the gastroenterologists,
et cetera, as part of multidisciplinary care team.
I think when we look at young people, what we really want to be focusing in on is building
their health literacy, their knowledge, skills, their confidence to start to engage in looking
after their own health.
We certainly see it a lot of the time for our patients because end of the day, the medications
that we do use, a lot of them are designed to suppress the immune system and do have
potential side effects.
So it's really firstly, as we've discussed, being open, non-judgmental and trying to explore
that anxiety and try and find out exactly which side effects they're particularly concerned
by.
For some people, if they've got good health literacy, discussing some of the evidence,
some of the data regarding those side effects and the relatively uncommon nature in which
a lot of them do occur.
And then also trying to marry that up with their current gut symptoms and the inflammation
and trying to have that discussion about benefits and risks.
And I guess some of the risks of not treating with effective medical management comes into
play.
So I think you need to set time for this.
It's certainly a conversation that I don't like to rush through and I want to explore
the patient's feelings as much as possible and try and work with them to try and overcome
some of that anxiety as best as possible.
So I think it's for patients who do have that coexisting mental health concerns, for people
who do have access or do see a psychologist, certainly involving them where possible, I
think it's really important.
And trying to bring in that multidisciplinary aspect of IBD care to assist with that anxiety
because it's all well and good for us as gastroenterologists to say, here, take this, you'll be great.
But on the flip side, if you're a patient, I'm sure many of them, as we've seen, do
have concerns and is trying to get into their shoes and trying to help them through that
journey when it comes to some of the medications that we use.
Thank you.
This podcast series is produced by Agpal as part of a consortium with Crohn's and Colitis
Australia and the Gastroenterological Society of Australia as part of an Australian Government
grant.
This is the seventh episode in our first series of Poo and A.
For more resources, including a suite of e-learning modules and live e-workshops, head to the
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