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Welcome to Episode 26 of Wrestling the Octopus IBD!

After 10 years studying IBD patients in remission, the first results from the PREdiCCt study have now been published - and it's essential reading: https://gut.bmj.com/content/early/2026/01/19/gutjnl-2025-337846

Nigel and I took the opportunity to sit down with Nathan Constantine-Cooke, a postdoctoral researcher from the University of Edinburgh and inflammatory bowel disease patient himself, to unpack these interesting first results from the UK's largest observational study on IBD flares.

Follow Nathan Constantine-Cooke on X/Twitter: @ibdnathan

With 2,629 patients recruited across 49 UK hospitals, the PREdiCCt study followed people in remission to understand what actually causes flares - and the findings challenge some long-held assumptions about gut health.

Key Takeaways

Calprotectin Matters - Even When You Feel Fine The study's most striking finding: faecal calprotectin strongly predicts flares even in patients feeling well. Clear separation emerged between three groups - below 50, 50-250, and above 250. The message for patient-centred care? Lower is better. Some patients had calprotectin levels above 2,500 while feeling completely fine, yet were at much higher risk of flaring. This reinforces the importance of treat-to-target approaches that prioritise biomarkers alongside symptom control.

Diet Does Matter - But It's Complicated Surprisingly, the study found different results for Crohn's disease versus ulcerative colitis:

• Ulcerative colitis patients: Higher meat consumption (including fish) linked to increased objective flare risk
• Crohn's disease patients: No significant meat association found
• No consistent links: Ultra-processed foods, fibre, alcohol and fats didn't show the expected connections to flares across either condition

These findings suggest a more nuanced approach to dietary advice in inflammatory bowel disease, moving away from one-size-fits-all recommendations.

Gender Differences Uncovered Women were more likely to report subjective flares. New research reveals pre-menopausal women showed higher calprotectin levels in remission, with irregular menstrual cycles and increased rectal bleeding during periods associated with patient-reported flares - crucial insights often overlooked in IBD care.

What This Means for You

As Nathan emphasises, medication remains paramount - diet modifications are supplementary, not substitutes. But for the first time, IBD patients have robust, evidence-based guidance on modifiable lifestyle factors that might influence our disease course.

Coming Soon: Additional papers examining psychosocial factors, genetics, microbiome data and women's health factors promise even deeper insights into personalised IBD management.

Listen now to understand how biomarker monitoring and thoughtful dietary choices could help you take more control of your gut health journey.

Follow Rachel at @bottomlineibd

Follow Nigel at @crohnoid

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We've seen a shift in mood around conversations on medical cannabis in inflammatory bowel disease.

While it's most definitely an area that needs tightly controlled monitoring and evidence-based advice, there's a thaw in the discussions that is seeing more IBD healthcare professionals having open talks with their patients about it - and vice versa.

So we were delighted when Dr Jami Kinnucan, IBD specialist at Mayo Clinic in Jacksonville, Florida - definitely the doyenne of complementary medicine in IBD - agreed to join us on this podcast episode to discuss a clear, evidence‑based look at medical cannabis use in Crohn’s disease and ulcerative colitis.

Key Topics Covered

• CBD vs THC:
  Cannabis contains hundreds of phytocannabinoids, but CBD and THC are the most clinically relevant. Both act on the endocannabinoid system, which has a high concentration of receptors in the gut - explaining potential effects on pain, nausea, appetite and motility.
• Integrative, not alternative:
  Dr Kinnuncan emphasises integrative medicine - evidence‑based therapies that complement IBD treatment. Cannabis should not replace proven medical therapies, as studies show it does not reduce inflammation or induce remission.
• What the research shows:
  Five randomised trials found no improvement in CRP, faecal calprotecti, or endoscopy.
  However, patients reported better:
  • abdominal pain
  • nausea
  • appetite
  • diarrhoea
  • sleep
  • quality of life
• Why open dialogue matters:
  Many patients assume “natural = safe” and hesitate to disclose cannabis use. But cannabinoids can interact with other medications via the liver. Honest, non‑judgmental conversations help clinicians spot interactions, hidden symptoms or missed diagnoses such as strictures or infection.
• Cannabis Hyperemesis Syndrome:
  A recognised condition causing cyclical vomiting in daily long‑term users. Hot showers may temporarily relieve symptoms. The only true treatment is stopping cannabis for 30+ days.
• Holistic IBD care:
  Dr Kinnucan discusses integrating lifestyle, diet, sleep, exercise, acupuncture, mindfulness and nutraceuticals (including emerging evidence for curcumin‑based supplements) alongside medical therapy.
• Practical advice for patients:
  If you’re considering cannabis, first ensure your inflammation is properly assessed and treated. Cannabis may help symptoms, but it can also mask problems that need medical attention.

Dr Kinnucan is on X: @ibdgijami

Follow Rachel at @bottomlineibd

Follow Nigel at @crohnoid

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In this episode of Wrestling the Octopus IBD, Nigel and Rachel talk with Mr Raj Mankotia, Consultant General and Colorectal Surgeon at Sandwell and West Birmingham Hospitals NHS Trust, to demystify the world of IBD-related surgery. With over 25 years’ experience, Raj talks us through first‑time elective or semi‑elective surgery for Crohn’s disease and ulcerative colitis - why it’s needed, what it involves and how patients can prepare for it.

1. Why Patients Are Referred for Surgery

Raj explains the two main pathways:

• Elective referrals
  • Failure of medical therapy
  • Persistent symptoms (urgency, bleeding, weight loss, malnutrition)
  • Pre‑cancerous changes or cancer found on surveillance colonoscopy
• Emergency referrals
  • Severe inflammation
  • Bleeding
  • Perforation

2. “Can I choose surgery instead of medication?”

Some patients doing well on medication may still prefer surgery. Raj explains:

• This is not a routine pathway
• Decisions are individualised
• Crohn’s patients will still need maintenance therapy after surgery

3. Fear of Surgery & Fear of Stomas

A major theme of the episode.

Raj discusses:

• How stoma decisions are made before surgery, not as a surprise
• The role of stoma nurses, psychologists and IBD teams in preparing patients
• Why emergency surgery often requires a temporary stoma

4. Common Misconceptions

The biggest one?

Raj explains why this is not true, and how decisions depend on:

• Disease location
• Nutritional status
• Steroid use

He also notes that many patients ultimately choose to keep their stoma because of the improvement in quality of life.

5. Crohn’s Surgery: Ileal / Ileocaecal Resection

Raj outlines:

• Why this is the most common Crohn’s operation
• What the surgery involves

He also discusses how recurrence rates have improved with modern biologics.

6. Ulcerative Colitis Surgery

Key points include:

• Around 20–30% of UC patients may need surgery
• Emergency surgery usually involves total colectomy, leaving the rectum
• Reasons for leaving the rectum include protecting pelvic nerves (bladder and sexual function)

7. J‑Pouch Surgery

Raj gives a realistic, balanced overview:

• Can be done laparoscopically
• A pouch is made from small bowel to mimic rectal function
• Outcomes vary:
  • ~50% have excellent function
  • ~50% have more challenging function

8. Preparing for Elective Surgery

Patients may be advised to:

• Optimise nutrition
• Taper steroids
• Stop smoking

9. Hospital Stay & Recovery

Typical expectations:

• Enhanced recovery programme
• Drinking on day 1, light food on day 2
• Early mobilisation

Raj also explains postoperative ileus - why it happens and how it’s managed.

10. What Patients Wish They’d Known

Raj shares reflections from his clinics:

• Many wish they’d had surgery earlier
• Many are surprised by how much better they feel
• Some who had emergency surgery and complications question the timing

If you have questions for future surgical episodes or topics you’d like covered:

📧

Follow Rachel at @bottomlineibd

Follow Nigel at @crohnoid