IBD

About inflammatory bowel disease (IBD)

 Inflammatory bowel disease (IBD):

 includes Crohn's disease (CD), ulcerative colitis (UC), and IBD-unspecified (or IBD-U).
 describes conditions with idiopathic, chronic, relapsing and remitting inflammation of the
gastrointestinal tract.
 is a chronic disease requiring lifelong care. There is no cure for IBD and its aetiology
remains incompletely understood.
 Both CD and UC have both similar and distinct clinical and pathological features with many
overlapping clinical, radiological, endoscopic and histological characteristics, but clear
differences in their typical distribution and extent of inflammation.
 The location and type of inflammation generally distinguish CD from UC:
 UC affects the colon only with continuous mucosal inflammation extending proximally
from the anus.
 CD can affect anywhere from the mouth to the anus (although disease distribution
usually remains stable in an individual). Common sites include the terminal ileum (70%),
and the colon (40%) often with transmural inflammation. CD is often discontinuous.
 IBD-U – about 5 to 15% of patients with IBD affecting the colon have features of both
conditions. Where a clear distinction cannot be made, the disorder is referred to as
IBD-U. Over time these cases will usually declare themselves as either CD or UC.
 Peak incidence is between 15 and 39 years but can occur at any age.
 Diagnosis is made by clinical, endoscopic, pathologic and radiologic means as required, with no
individual technique being 100% diagnostic.
 The overall incidence of IBD in Australia is around 30 per 100,000, whereas IBS affects up to 10
to 15%. IBD affects approximately 85,000 people in Australia.
 A diagnosis of IBD vs IBS can usually be made on clinical grounds supported by simple
investigations.

Assessment
1. Take a history. Check symptoms to distinguish IBD from other more common conditions, and to
assess disease severity.

Symptoms

IBD shares symptoms with other more common conditions:

  Diarrhoea:

Commonly bloody in ulcerative colitis (UC).

Can be associated with urgency and tenesmus as UC gets more severe (due to rectal
inflammation).

 The need to pass stool at night, awakening from sleep or faecal incontinence is highly
suggestive.

 Abdominal pain:

Not a good discriminating symptom as it is present in many other conditions e.g., IBS, infectious
gastroenteritis.

Occurs prior to defecation in UC and can be colicky due to partial obstruction in ileal Crohn's
disease (CD).

 If peritonism is present on physical examination, this is a medical emergency.

 Rectal bleeding

 Fever – more often present in CD, but if UC is severe, can also be noted.

 Weight loss – more common in CD.

 Malaise, anorexia, and vomiting – more common in CD.

 Tachycardia – non-specific for IBD, but if present it is a sign of severity.

History of illness

 The history of illness is one of the most helpful factors in discriminating between IBD and other
causes of similar symptoms.
 An abrupt onset is uncommon in IBD and suggests infection.
 A more gradual onset with a crescendo or fluctuating pattern is more common in IBD
and more suggestive of it. However, long-standing fluctuating symptoms also favour
a diagnosis of IBS or other functional gastrointestinal disorders (FGID).
 Ask about any travel history.

 family history for IBD, colorectal cancer, coeliac disease, and autoimmune disease.
 medications, especially NSAIDs causing NSAID enteropathy, antibiotics, and laxatives.
 smoking.

Smoking

Check timing relative to IBD symptoms as there is a paradoxical relationship between smoking
and IBD:
  Smoking increases the risk of developing and significantly worsens the course of
Crohn's disease (CD), but reduces the risk of developing ulcerative colitis (UC).
 Smoking cessation may worsen UC.
 life interference.

Life interference

For example:

 Missing out on work or social activities

 Mood disorders – relevant to severity assessment, but does not help discriminate between
IBD and other differential diagnoses

 vaccination history.
2. Consider major differential diagnoses.

Differential diagnoses

 Infectious gastroenteritis:
 Common
 Short-lived, abrupt onset, and symptoms are at their worst soon after starting
 Contacts with similar illness
 Travel
 Irritable bowel syndrome (IBS)
 Diagnostic tools can help distinguish between IBS and IBD:

 Differentiating between IBS and IBD

 IBS4GPs

 50 times more common than IBD.

 Long-standing, with no warning signs of IBD, fluctuating severity, no abnormal
blood tests.

Warning signs of IBD

New symptoms < 6 months

 Rectal bleeding
 Unexplained weight loss or fever
 Abdominal mass
 Nocturnal symptoms
 Severe perianal pain or discharge
 Extraintestinal symptoms
 Family history of IBD
 New symptoms in a patient aged > 50 years
 Nocturnal symptoms are unusual.
  Faecal calprotectin is low, and has been found to be highly accurate in this
setting precluding the need for more expensive and invasive tests such as
colonoscopy.
 Coeliac disease:
 Where there is diarrhoea without blood as the predominant feature, with or without
malabsorption.
 More common than IBD.
 Colorectal cancer:
 Also presents with rectal bleeding, abdominal pain, significant weight loss, and
sometimes diarrhoea with urgency.
 Often an older patient.
 Increasingly common from age 50 years.

3. Examination:
 Check vital signs – weight, BMI, pulse rate, blood pressure, temperature, signs of anaemia
and fluid depletion.
 Perform abdominal examination, looking for tenderness, distension, masses. If peritonism
is present, this is a medical emergency.
 Examine the perianal region for tags, fissures, fistulas, abscess. Perform rectal
examination.
 Perform oral inspection.
 Look for extra-intestinal manifestations of IBD.

Extra-intestinal manifestations of IBD

 Skin e.g., erythema nodosum, pyoderma gangrenosum

 Arthritis
 Eye e.g., episcleritis, iritis
 Mouth ulcers
 Night sweats
 Primary sclerosing cholangitis
4. Check for complications of IBD.

Complications

 Intestinal obstruction:

 Due to strictures

 More common in CD

 Fistulae:

 Often perianal

 In CD
  Abscesses – in CD

 Nutritional deficiencies and malabsorption – in CD. Many patients manage their IBD with
dietary restrictions.

 Anaemia:

 Due to blood loss and decreased nutrient intake

 In CD and UC

 Acute abdomen (shock and peritonism)

 Sepsis

In severe cases, Crohn’s disease may cause complications that necessitate emergency surgery,
including:

 Fissures: These are tears in your anus resulting in symptoms such as abdominal pain and blood
in your stool during bowel movements.
 Anal fistula: Fistula is an abnormal connection that forms in the same organ or between two
organs. It can also form between one part of the intestine and another or between the intestine
and bladder, vagina or skin. It is most common in the anal area.
 Ulcers: Ulcers are open sores that can develop anywhere in your colon, including your anus.
 Strictures: Stricture is a narrowing of the intestine due to long-term inflammation.
 Bowel obstruction: Strictures in many parts of the bowel can block the flow of digestive
contents through the organ in a condition known as bowel obstruction.

As Crohn’s disease progresses, you may develop other complications that affect your overall health and
quality of life, which include:

 Anemia
 Mouth sores
 Skin disorders (bumps and rash)
 Arthritis (swollen and painful joints)
 Osteoporosis
  Gallbladder disease
 Liver disease
 Kidney stones
 Redness or pain in the eyes
 Vision changes
 Fever
 Loss of appetite
 Weight loss
 Fatigue
 Night sweats
 Loss of normal menstrual cycle

Crohn’s disease elevates your risk of colon cancer,

5. Investigations – there is no one test which can reliably diagnose every case of IBD, particularly if
mild disease. In suspected IBD, tests are aimed at differentiating IBD from the main differential
diagnoses (particularly IBS), and helping to define current IBD activity and severity.

 Arrange initial tests for all patients.

Initial tests

 FBC – may show anaemia usually iron deficiency (vitamin B12 deficiency can also occur if
severe or long segment ileal disease).

 CRP or ESR – may be helpful if elevated but normal values do not exclude inflammation
(especially in UC where they are usually normal except in severe disease).

 E/LFT – low albumin due to inflammation and malnutrition. Elevated creatinine/urea due
to dehydration. Electrolyte disturbances due to poor diet and diarrhoea with low
magnesium, selenium, potassium and zinc also possible.

 Coeliac screen – if no blood in the stool and no abdominal mass.

 Faecal culture (ova and parasites if appropriate) with PCR testing for faecal pathogens
(only appropriate if symptoms < 6 weeks).

 Clostridium difficile (C. difficile) toxin (when acute increase in symptoms).

  Iron studies – with low ferritin and transferrin saturation. Ferritin may be normal or
elevated in the setting of inflammation. Order this test if there is anaemia or abnormal
red cell indices.

 Faecal occult blood – there is no role for this test in the investigation of IBD.

 Consider arranging:

 faecal calprotectin

Faecal calprotectin

Faecal calprotectin is a:

 recommended test, which from1 November 2021 is now funded by the MBS for
diagnostic purposes when ordered by a medical practitioner.

 sensitive, non-invasive marker of intestinal inflammation, and can be useful in the

following settings:

 Differentiating between those with and without current inflammation in the

lower gut needing further evaluation.

 Distinguishing between people with IBS and IBD. Can cost between $80 to
$100 – but easier than a colonoscopy. Particularly useful for rural patients
where access to colonoscopy can involve travel and extended waiting
times.

 It is used to monitor IBD patients on therapy to determine whether there is

current disease activity and risk of relapse, response to treatment.

 There is potential for false positive results in infectious diarrhoea in the

absence of IBD. Therefore do not use where diarrhoea is present for
< 6 weeks.

 It is not useful when there is PR bleeding from any cause as it will be high.

 other investigations – these are mostly arranged by specialist.

Other investigations

 Colonoscopy with ileoscopy – to establish the diagnosis of IBD and assess

severity and extent. Screening colonoscopy for dysplasia surveillance.

 Upper gastrointestinal endoscopy – for upper GI symptoms.

 Capsule endoscopy – in limited circumstances.

 Abdominal X-ray – can show bowel obstruction and toxic megacolon.

  CT abdomen – to assess disease extent and severity and look for complications.
USS and MRI are now preferred due to radiation dose.

 Ultrasound abdomen.

 MR enterography.

Management
1. If any red flags, arrange immediate emergency assessment.

Red flags

Abscess

 Bowel perforation
 Bowel obstruction
 Systemic toxicity (e.g., toxic megacolon)
2. Manage according to patient presentation:

 First presentation – acute disease

0. If symptoms and signs of an acute abdomen, arrange immediate emergency assessment.

1. If acutely unwell with ulcerative colitis (UC) or Crohn's disease (CD), request acute

gastroenterology assessment or acute general medical assessment.

Acutely unwell

Criteria for an acutely unwell patient with:

 ulcerative colitis (adapted from the Truelove and Witts criteria):

 > 6 bloody bowel motions per day, and

 ≥ 1 of:

 Temperature > 37.8°C

 Heart rate > 90 beats a minute

 Haemoglobin < 105 g/L

 CRP > 30

 Crohn's disease:
  Fever

 Recent weight loss of > 5 kg

 Tachycardia

 Unable to take part in normal activities

2. If patient at high risk of a poor outcome, request prompt acute gastroenterology

assessment.

High-risk patients

 Weight loss > 5 kg at presentation

 Poor appetite and decreased oral intake

 Need for steroids at first presentation

 Unable to manage usual activities

 Reliance on opioids for pain relief

 Mood disorders, on antidepressants

3. If concerns regarding whether hospital admission may be required, seek gastroenterology

advice and ask to speak to the gastroenterology registrar or consultant on call, or
seek general medical advice.

4. Review blood test results.

 Do not delay requesting specialist advice or hospital care while waiting for test
results. Judge severity without laboratory testing.

 If results show anaemia, leucocytosis, thrombocytosis, or increased CRP, this

suggests IBD. Seek gastroenterology advice or general medical advice.

5. If not acutely unwell, but IBD is suspected, request non-acute gastroenterology

assessment or acute general medical assessment for consultation.

 Continue monitoring patient closely, as they can become acutely unwell while
waiting for a clinic appointment.

 If symptoms worsen, consider seeking gastroenterology advice or general medical

advice, or arranging emergency assessment. The patient may require urgent
investigations to confirm diagnosis.

6. Consider goals of therapy.

Goals of therapy
  Treat acute disease to reduce or control intestinal inflammation, prevent the next
flare, and heal the mucosa. Minimise side-effects and long-term adverse effects.

 Correct nutritional deficiencies.

 Induce remission, and then maintain steroid-free remissions.

 Prevent complications, hospitalisations, and surgery.

 Normalise quality of life. Life expectancy is normal with appropriate

management.

See Medications – Inflammatory Bowel Disease.

7. Request dietitian assessment:

 for all patients at least once.

 if weight loss > 5% or nutrient deficiencies.

Dietitians specialising in gastrointestinal disorders can be located via Dietitians

Association of Australia.

8. Check other considerations:

 Risk of osteoporosis – check bone density if repeated courses of prednisone, or low

vitamin D levels.

 Risk of opportunistic infections.

Risk of opportunistic infections

 Possibility of infections such as tuberculosis, listeria, legionella, hepatitis

B and C, varicella, and fungi due to immunosuppression (increased by
immunomodulators, long-term steroids, and biologics, especially if on > 1
medication).

 Encourage early presentation if unwell.

 Confidence and self-image – depression is more frequent in IBD.

 Extra-intestinal manifestations.

Extra-intestinal manifestations of IBD

 Skin e.g., erythema nodosum, pyoderma gangrenosum

 Arthritis

 Eye e.g., episcleritis, iritis

  Mouth ulcers

 Night sweats

 Primary sclerosing cholangitis

9. Arrange regular follow-up with patient to understand disease behaviour and severity, and to
identify patients at risk of a poor outcome.

Patients at risk of a poor outcome

 Poor response to therapy

 Disease is progressive

 Intolerance, or non-adherence to therapy

 Patient needs early treatment intensification.

 Ongoing (routine) management

Always undertaken in association with a gastroenterologist or IBD specialist. Long-term
maintenance therapy is the standard of care for the maintenance of remission in IBD.

0. Check medications. See Medications - Inflammatory Bowel Disease for details.

1. If medical therapy not controlling symptoms, and mechanical complications arise e.g.,
stricture, obstruction, perforation, abscess or refractory bleeding, request acute
gastroenterology assessment.

2. Consider goals of therapy.

Goals of therapy

 Treat acute disease to reduce or control intestinal inflammation, prevent the next
flare, and heal the mucosa. Minimise side-effects and long-term adverse effects.

 Correct nutritional deficiencies.

 Induce remission, and then maintain steroid-free remissions.

 Prevent complications, hospitalisations, and surgery.

 Normalise quality of life. Life expectancy is normal with appropriate

management.
 See Medications – Inflammatory Bowel Disease.

3. Review other considerations:

 Risk of osteoporosis – check bone density if repeated courses of prednisone, or low

vitamin D levels.

 Risk of opportunistic infections.

 Confidence and self-image – depression is more frequent in IBD.

 Extra-intestinal manifestations.

 Major surgery – if the patient has major surgery scheduled, seek gastroenterology

advice or general medical advice.

4. Arrange follow-up. Use practice recall software to ensure an appropriate follow-up regime.

 Maintenance care and follow-up for specific patients

Maintenance care and follow-up for specific patients

 Well patients not on immunosuppression:

 Arrange:

 at least annual general practitioner and specialist review.

 annual FBC and biochemistry

 annual physical check-up and weight

 bone density scan if prior low bone density or steroid use

 Consider treatment intensification, if symptomatic periods over the

preceding year

 Well patients on immunosuppression:

 Arrange:

 three-monthly blood tests (FBC, E/LFTs)

 regular review to detect complications and monitor disease

activity

 Consider 6 to 12-monthly faecal calprotectin as a biomarker of

disease activity

 Patients with long standing colitis > 8 years:

  Undertake colonoscopic surveillance.

 Regularly screen for colon cancer.

Regular screening for colon cancer

 There is increased risk of colon cancer for both

ulcerative colitis and Crohn's colitis.

 The main risk is related to the duration, extent, and

activity of the disease rather than the type of IBD.

 A baseline colonoscopy is offered at about 8 years after

the initial onset of symptoms.

 Further surveillance colonoscopies are performed every

1 to 5 years, depending on the:

 duration.

 extent of disease.

 presence of additional risk factors will increase

the frequency of surveillance as they increase risk
significantly e.g., family history of bowel cancer.

 Patients with known significant length of small intestinal CD – arrange

malabsorption screen annually, including iron studies, vitamin D, B12, and
folate.

 Routine follow-up for all patients

Routine follow-up for all patients

 Ensure adherence with medication.

 Check if the patient is in remission.

 Organise routine blood tests and faecal calprotectin as above. Note that
faecal calprotectin is more useful than any blood tests in providing
information about disease activity.

 Identify and minimise side-effects of medication.

 Ask the patient about psychosocial problems. Consider arranging GP

Mental Health Treatment Plan if indicated.

 Consider bone densitometry if weight loss or steroid use.

  Ensure vaccinations are up to date. Do not give live vaccines if patient is
on, or about to start, immunosuppressants or steroids.

 Annual influenza vaccine if on immunomodulators

 Appropriate pneumococcal vaccine if on immunomodulators

 Hepatitis B vaccine – check titre if unsure

 HPV vaccine in adult women on immunomodulators

 Varicella zoster vaccine. This is a live vaccine – do not give if

patient is on, or about to start, immunosuppressants or steroids.

 Ensure annual non-acute gastroenterology assessment.

 Ensure non-acute gastroenterology assessment for colorectal cancer

surveillance.

5. Advise the patient about:

 smoking.

Smoking

Check timing relative to IBD symptoms as there is a paradoxical relationship

between smoking and IBD:

 Smoking increases the risk of developing and significantly worsens the

course of Crohn's disease (CD), but reduces the risk of developing
ulcerative colitis (UC).

 Smoking cessation may worsen UC.

 maintaining good nutritional status

Maintaining good nutritional status

Unusual dietary habits are common in patients with IBD, and under-nutrition has a
negative impact on clinical course, rate of postoperative complications, and
mortality. All patients require at least one dietitian assessment upon diagnosis.

 Encourage a healthy balanced diet. Diet may be helpful in reducing

symptoms and lessening the effects of IBD complications. 1

 Consider and treat any nutritional deficiencies, e.g:

 iron, vitamin B12, vitamin D – patients with ileal involvement or

resection should have regular B12 screening.
  vitamin K, zinc, and folate deficiencies (less common).

 Ensure patients treated with MTX are supplemented with folic acid.

 If active Crohn disease, be aware that malnutrition with weight loss,

protein deficiency, and specific deficiencies in vitamins, minerals, and
trace elements are common.

 Request dietitian assessment:

 for all patients at least once.

 if weight loss > 5% or nutrient deficiencies.

Dietitians specialising in gastrointestinal disorders can be located

via Dietitians Association of Australia.

 risk of opportunistic infections.

 Contraception, pregnancy, breastfeeding, and IBD

0. Discuss contraception.

Contraception

 If small bowel involvement in CD, combined oral contraceptive pill (COCP)

absorption may be reduced. (Large bowel involvement does not affect
absorption.)

 Do not use COCPs in patients prone to severe hospitalised exacerbations, as their

risk of venous thromboembolism (VTE) is increased.

 IBD increases the risk of osteoporosis, and the effect of Depo-Provera on bone
density may be additive. Progestogen-only contraceptives that do not affect bone
density may be preferred.

For more information on contraception in IBD, see FSRH – Sexual and Reproductive Health
for Individuals with Inflammatory Bowel Disease (page 7, table 3).

1. Advise about fertility:

 Ulcerative colitis (UC) does not affect fertility, unless patients have severely active
disease or previous pelvic surgery e.g. proctectomy or ileo-anal pouch surgery.

 In IBD, the main factor in fertility relates to good disease control e.g., the better the
disease control, the more likely to get pregnant.
2. Consider perinatal planning.

Perinatal planning

 Before conception, good control of IBD is important. Continue all medications

except methotrexate before and during pregnancy.

 Methotrexate is absolutely contraindicated in pregnancy. Both women and

men should delay a pregnancy for at least 3 to 6 months after stopping
the drug.

 Never give live vaccines to infants in the first 6 months after birth for
patients on immunosuppression and biologics. In general, do not give live
vaccines for 12 months, and only after 6 months following discussion with
a gastroenterologist.

 Consider using a higher dose of folic acid (5 mg) for women taking sulfasalazine,
or those with malabsorption following small bowel resection.

 If planning a pregnancy, request a non-acute gastroenterology assessment.

 See also Pre-conception Consultation.

3. Consider goals of therapy.

Goals of therapy

 Treat acute disease to reduce or control intestinal inflammation, prevent the next
flare, and heal the mucosa. Minimise side-effects and long-term adverse effects.

 Correct nutritional deficiencies.

 Induce remission, and then maintain steroid-free remissions.

 Prevent complications, hospitalisations, and surgery.

 Normalise quality of life. Life expectancy is normal with appropriate

management.

See Medications – Inflammatory Bowel Disease.

4. Discuss medication risks and benefits in pregnancy and while breastfeeding.

Medication risks and benefits

 Methotrexate – absolutely contraindicated in pregnancy. Both women and men

should delay a pregnancy for at least 3 to 6 months after stopping the drug.

 5-ASA – safe to continue in pregnancy and breast feeding.

  Steroids – seek gastroenterology advice or general medical advice.

 Thiopurines e.g., azathioprine (Aza), 6 mercaptopurine (6 MP):

 Safe to use during pregnancy.

 These drugs do not affect spermatogenesis, so potential fathers should

continue therapy.

 Biologicals e.g., adalimumab, infliximab:

 Seek obstetric advice regarding use during pregnancy.

 No significant abnormalities to date.

 Babies exposed in utero may be immunosuppressed:

 Never give live vaccines to infants in the first 6 months after birth

for patients on immunosuppression and biologics. In general, do
not give live vaccines for 12 months, and only after 6 months
following discussion with a gastroenterologist.

 Give inactivated vaccines according to the recommended

schedule. Additional inactivated vaccine doses may be required, as
immune responses may be suboptimal. Seek paediatric specialist
advice.

 Except methotrexate, all above medications are safe in breastfeeding.

5. Request dietitian assessment:

 for all patients at least once.

 if weight loss > 5% or nutrient deficiencies.

Dietitians specialising in gastrointestinal disorders can be located via Dietitians

Association of Australia.

6. When a pregnancy is confirmed, request a non-acute gastroenterology assessment or

a non-acute general medical assessment. Consider requesting non-acute obstetric
assessment for IBD patients on immunosuppressants and biologics.

 Flare-ups
In IBD flare-ups, symptoms are common but not all symptoms are due to increased inflammatory
activity.
0. Differentiate between:

 active IBD – more drug therapy may be warranted.

 non-inflammatory symptoms (mechanical, food sensitivity, or IBS-type) – these will

require other treatment approaches.

1. If non-inflammatory causes, manage according to condition diagnosed.

2. Consider goals of therapy.

3. If active inflammatory IBD:

 do not prescribe long-term or recurrent prednisone.

 check adherence to therapy. The most common cause of a flare in IBD is non-
adherence.

 request non-acute gastroenterology assessment for steroid-sparing treatments.

4. If ulcerative colitis, optimise 5-Aminosalicylate (5-ASA):

 Increase oral 5-ASA e.g., 4 g per day as a daily dose.

 Start rectal 5-ASA e.g., enemas if left-sided disease. Can be difficult to hold but
encourage patient to persist (best given at night before bed).

 Use suppositories for proctitis.

 If on maximal 5-ASA, or limited response after 1 week:

 start prednisone. Indefinite prednisolone is not appropriate, so

seek gastroenterology advice or general medical advice.

 seek gastroenterology advice or general medical advice to consider further

treatment.

 depending on advice, request non-acute gastroenterology assessment to

consider starting an immunomodulator.

5. If Crohn's disease:

 seek gastroenterology advice or general medical advice to consider further

treatment.

 consider starting prednisolone, budesonide, or adjusting the dose of biologic based

on specialist advice.

 depending on advice, request non-acute gastroenterology assessment to consider

starting an immunomodulator or biologic.
 6. If unsure about the best medication to use:

 seek gastroenterology advice or general medical advice.

 consider requesting acute gastroenterology assessment or acute general medical

assessment, especially if patient is already on an immunomodulator or biologic.

7. Request dietitian assessment:

 for all patients at least once.

 if weight loss > 5% or nutrient deficiencies.

Dietitians specialising in gastrointestinal disorders can be located via Dietitians

Association of Australia.

Request
 If any red flags, or symptoms and signs of acute abdomen, arrange immediate emergency
assessment.

Red flags

 Abscess
 Bowel perforation
 Bowel obstruction
 Systemic toxicity (e.g., toxic megacolon)
 Request acute gastroenterology assessment or acute general medical assessment if diagnosed or
suspected IBD, and acutely unwell with ulcerative colitis or Crohn's disease.

Acutely unwell

Criteria for an acutely unwell patient with:

 ulcerative colitis (adapted from the Truelove and Witts criteria):

 > 6 bloody bowel motions per day, and
 ≥ 1 of:

 Temperature > 37.8°C
 Heart rate > 90 beats a minute
 Haemoglobin < 105 g/L
 CRP > 30
 Crohn's disease:
 Fever
 Recent weight loss of > 5 kg
  Tachycardia
 Unable to take part in normal activities
 If patient not acutely unwell but IBD suspected, request non-acute gastroenterology
assessment or acute general medical assessment.
 If patient at high risk of a poor outcome, request prompt acute gastroenterology assessment.
 If medical therapy not controlling symptoms, and mechanical complications arise, request acute
gastroenterology assessment.
 Request non-acute gastroenterology assessment if:
 first presentation, and IBD is highly likely (i.e., patient has symptoms and suspicious blood
test results, or positive faecal calprotectin), or diagnosis by colonoscopy.
 flares, especially if steroids are used.
 unsure about medications, orconsidering starting an immunomodulator or biologic.
 pregnancy is planned or confirmed, especially if patient on immunosuppressants and
biologics.
 Request non-acute gastroenterology assessment or acute general medical assessment if:
 patient not acutely unwell but IBD suspected.
 pregnancy is suspected or confirmed.
 If symptoms worsen, seek gastroenterology advice or general medicine advice, or
arrange emergency assessment for possible urgent investigations to confirm diagnosis.
 Seek gastroenterology advice or general medical advice if:
 blood tests suggest IBD (presence of leucocytosis, thrombocytosis, increased CRP).
 concerns regarding whether hospital admission necessary.
 any major surgery scheduled.
 considering giving steroids.
 significant anaemia or other abnormal tests.
 needing help with use of medications, including 5-ASA drugs.
 Consider requesting acute gastroenterology assessment or acute general medicine assessment if
unsure about the best medication, especially if patient is already on an immunomodulator or
biologic.
 Request dietitian assessment:
 for all patients at least once.
 for specific nutritional advice.
 If weight loss > 5% or nutrient deficiencies.

Dietitians specialising in gastrointestinal disorders can be located via Dietitians of Australia.

 Request non-acute gastroenterology assessment:

 if planning a pregnancy.
 for colorectal cancer surveillance.
 annually as part of follow-up.
 Seek obstetric advice or paediatric specialist advice regarding use of biologicals during pregnancy.