What are the Early Warning Signs of an IBD Flare Up?

Most of the time the cause of a Crohn’s flare is unknown.

But the most common causes of flares include:

• Non adherence: Not taking medications as instructed
• Medications: Taking a non-steroidal anti-inflammatory medicines (NSAIDs) such as aspirin  and ibuprofen
• Diet: Eating too much of foods that the bowel can’t process or handle
• Other possible causes of flares include:
  • Smoking
  • Alcohol
  • Stress
  • Antibiotics, which can alter the amount and type of bacteria that normally live in your gut, triggering diarrhoea or inflammation.
• There are other causes of flares: disease complications like fissure, fistula, stricture, or abscess.

Early Warning Signs

Below is the scale of symptoms and how to seek the most appropriate help when you experience these. Please note: You might have one or multiple symptoms at one time. You may also experience some of these more acutely than others. What is important is ‘does this feel different to my own normal’?

Mild symptoms that would require OTC treatment:

• Feeling generally unwell.
• Diarrhoea – This is can sometimes mixed with blood, mucus and pus. This can be treated effectively with anti-diarrheals.
• Loss of appetite and loss of weight.
• Mouth ulcers –This is specific to CD patients.
• Trouble sleeping – Many people with IBD have problems falling asleep or staying asleep. There are several reasons for this; including pain, diarrhea, or fevers. Certain medications, such as prednisone, can also make getting to sleep more difficult. In some cases, having problems with sleep might start to occur even before a flare-up starts. In other words, poor sleep might even be an early sign of an IBD flare-up. For this reason, it is important for those with IBD to take care to get enough rest.

Moderate symptoms that would require contact GP or IBD nurses:

• This will also include symptoms which has not responded to three days of OTC treatment.
• Unexplained fever – A fever can be a good indication that there is inflammation somewhere in the body. IBD causes inflammation in the intestinal tract, and that in turn, could wind up causing a widespread fever. And when the cause of a fever can’t be found, such as a viral illness like the flu, it could be a result of an IBD flare-up, especially if there are other signs and symptoms of a flare up occurring. If a fever is not going away in a few days, it should be discussed with  your GP.
• Blood in the stool – One of the more common signs of UC, but it does happen in CD patients, less frequently. There are many possible causes of blood in the stool, but for those who have already been diagnosed with IBD; bright red blood in the stool is probably a good indication that the IBD is flaring up.
• Joints – Inflammation of the joints, often known as arthritis, means that fluid collects in the joint space causing painful swelling.  It usually affects the large joints of the arms and legs, including the elbows, wrists, knees and ankles.
• Eye inflammation – The most common eye condition affecting people with IBD is episcleritis, which affects the layer of tissue covering the sclera, the white outer coating of the eye, making it red, sore and inflamed.

Severe symptoms that require immediate medication attention:

• Abdominal pain – Pain from UC tends to be located in the lower left quadrant of the abdomen and patients is often describe it as being crampy in nature. Pain from CD could be located in almost any area of the abdomen, depending on what section of the intestine is affected. In the two most common forms of CD, ileocolitis and ileitis, pain might be found in the middle or the lower right abdomen. Pain in the abdomen has many potential causes; for that reason, the location is an important factor in helping a physician understand and diagnose what might be causing it!
• Anaemia (a reduced number of red blood cells) – You are more likely to develop anaemia if you are losing a lot of blood and are not eating much.
• Persistent diarrhoea – One of the more troublesome symptoms of IBD, diarrhoea can also be an indication of a flare-up, especially if it is bloody. Some people with IBD also experience an intense need to move the bowels (called tenesmus) along with the diarrhoea. Diarrhoea happens to everyone, but diarrhoea that is not caused by IBD (such as that caused by common illnesses) will typically go away by itself in a few days. With IBD, diarrhoea will not resolve on its own. For most people, the normal range for bowel movements is between one and three a day. During a flare-up, people with IBD could experience many more – in a severe case, that could mean 10 or more bouts of diarrhoea a day. Diarrhoea that is accompanied by blood or abdominal pain should always be discussed with your GP or specialist team as soon as possible, even if those symptoms have happened before.

The location of your disease may determine what kind of symptoms you have

Crohn’s disease:

Ileocolitis – Affects the end of the small intestine (the ileum) and the large intestine (the colon). Symptoms include weight loss, diarrhea and cramping or pain in the middle or right lower abdomen.

Ileitis – Affects the ileum. Symptoms include weight loss, diarrhoea and cramping or pain in the middle or right lower abdomen.

Jejunoileitis – Characterised by patchy areas of inflammation in the upper half of the small intestine (the jejunum). Symptoms include mild to strong abdominal pain and cramps following meals, as well as diarrhoea.

Gastroduodenal Crohn’s disease – Affects the stomach and the beginning of the small intestine (the duodenum). Symptoms include loss of appetite, weight loss, nausea, and vomiting.

Crohn’s colitis – Affects the colon. Symptoms include diarrhoea, rectal bleeding, and disease around the anus (abscess, fistulas, ulcers).

Ulcerative Colitis:

Ulcerative Proctitis – Affects the rectum. Symptoms include rectal bleeding, rectal pain, and a feeling of urgency.

Proctosigmoiditis – Affects the rectum and sigmoid colon (the lower segment of the colon right above the rectum). Symptoms include bloody diarrhoea, pain in the lower left side of the abdomen, and a constant feeling of the need to pass stools (tenesmus).

Left-Sided Colitis – Affects the rectum and extends as far as a bend in the colon near the spleen. Symptoms include bloody diarrhoea, pain in the left side of the abdomen, loss of appetite, and weight loss.

Pan-Ulcerative Colitis – Affects the entire colon. Symptoms include bloody diarrhoea, severe abdominal pain, loss of appetite, and weight loss.

How can you ‘self manage’ your IBD?

The typical symptoms of IBD — stomach cramps, abdominal pain, and diarrhoea  — come and go. Keep in mind that the duration of flare-ups can be unpredictable and that remissions can vary in length, which means you always need to be on alert for any new or different symptoms.

A flare can last several days and go away on its own. Or you can have a flare that gets progressively worse and requires surgery. This is because each flare can produce an injury to the bowel, and frequent untreated flare ups can trigger complications like intestinal obstruction, as well as systemic problems such as anemia, bone loss, or clotting issues.

Preventing flares before they occur with an effective medical maintenance regimen can change the path of your IBD. As soon as you suspect a flare is occurring, it’s important that you take steps to control it.

How you can help:

1. No one diet can prevent or reduce discomfort from flares, but there are a few general principles that may help. Eating food which are easy to digest as well as drinking plenty can help aid digestive transit and recover the bowel lining.
2. Reducing stress is another smart strategy. Make sure you’re getting adequate sleep and doing relaxing activities like yoga, meditation, and mindfulness; can help reduce the body’s response to inflammation.
3. Over-the-counter medications may also help relieve some symptoms of flares. For example, anti-diarrheal medications can reduce the frequency of diarrhea episodes, while acetaminophen is generally a safe medication that can ease the pain.
4. Finally, your consultant may need to adjust your medications during your flare. That’s why when you have IBD, it’s important to have good communication with your gastroenterologist. The most important ‘control’ you have to prevent flare-ups is to continue your maintenance medications, as directed.

Are there any exceptions to the ‘rules’?

If you notice more than six bowel movements per day that include a lot of blood, accompanied by a fast heart rate and a fever or a low temperature seek immediate medication attention.

In UC, Toxic Megacolon is a potentially life-threatening complication.

This is where a portion of the large intestine becomes paralysed, stops working, and swells to many times its normal size. This is an urgent condition that requires immediate medical attention. If left untreated, a portion of the intestine could be so severely damaged that it develops a hole or perforates, possibly leading to severe infection and even death.

Signs of toxic megacolon include:

• Worsening abdominal pain
• A visibly distended or bloated abdomen
• Abdominal tenderness
• High fever
• Dehydration
• A sudden decrease in the number of bowel movements

In CD, three things are a major cause for concern:

Intestinal Obstruction – The most common complication of CD, obstruction may arise from swelling and the formation of scar tissue. The result is thickening of the bowel wall and a narrowed intestinal passage. These narrowed areas are called strictures. Strictures may be mild or severe, depending on how much they obstruct the passage of the bowel’s contents.

Symptoms of intestinal obstruction include:

• crampy abdominal pain
• frequently associated with vomiting
•  bloating.

Medications may relieve the obstruction by reducing the local area of inflammation. If the obstruction is severe and does not respond to medical treatment, surgery may be required. Surgery also may be indicated if the blockage recurs frequently.

Abscesses – An abscess is a localised pocket of pus caused by infection from bacteria. More common in Crohn’s than in Colitis, an abscess may form in the intestinal wall—sometimes causing it to bulge out. Visible abscesses, such as those around the anus, look like boils and treatment often involves lancing.

Symptoms of an abscess include

• swelling
• tenderness
• pain
• fever.

Once the abscess is drained, the symptoms resolve. Antibiotics are usually given to clear up the remaining infection.

Fistulas – Deep sores or ulcers within the intestinal tract may turn into tracts—called fistulas—that connect different parts of the intestine. Fistulas also may tunnel into the surrounding tissues of the bladder, vagina, or skin. These abnormal passages, which affect about 30% of people with Crohn’s disease, often become infected. If the fistula is small, antibiotics and other medical treatment may be adequate. Large or multiple fistulas, on the other hand, may require surgery, especially if they cause persistent symptoms.

Symptoms of a fistula include:

• Pain and swelling around the anus.
• Pain with bowel movements.
• Bleeding.
• Bloody or foul-smelling drainage (pus) from an opening around the anus.
• Irritation of the skin around the anus due to persistent drainage.
• Fever

Conclusion

It is important to know that despite all these warnings, the body can just flare up without rhyme or reason. If you are ‘careful’ and maintain a good diet and healthy wellbeing whilst your disease is stable, having a flare up can come as a surprise. It also comes with a lot of emotions including anxiety and worry. These are normal things to feel and in no way should you feel guilty.

What is important is keeping in contact with your IBD team. Maintain your regular check ups with them within a clinic setting and make use of your IBD nurses, if you have one. Whilst this is something that is dealt with a NHS Trust level, Crohn’s & Colitis UK have a dedicated section of their website for IBD Nurse Specialist – locate a local nurse, how the system of contact them works and what to do outside of consulting times.

They have also created the IBD Standards which NICE have set out guidelines for how IBD should be diagnosed, managed and treated; with both surgery and medication. It is a document which has been greatly praised and well received.

How do you manage your flare ups when they occur? Do you track habits, patterns or symptoms to avoid future flare ups? Have you had flares that change your disease progression – ie needing surgery or changing treatment plans?

Do you have any questions or queries? Or just want to share your own experiences? Leave me a reply or tweet me @sapphire20 or find my blog page on Facebook!

Sources:

VeryWellHealth – Signs Your IBD May Be Flaring

Crohns and Colitis UK – What are the symptoms?

Mayo Clinic – Ulcerative Colitis: Symptoms  and Crohn’s disease: Symptoms

Everyday Health – Caregiver Tips: Knowing the Warning Signs of a Colitis Emergency

CrohnsandColitis – Crohns Disease Symptoms

Everyday Health – Is it a Crohn’s Flare? How to Spot the Signs

Healthline – How to Know if Your Crohn’s is Advancing

Crohns & Colitis Foundation – Intestinal Complications

Cleveland Clinic – Anal Fistula Symptoms, Surgery & More