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We can hardly believe it's been 12 whole months since we started this podcast on patients' reflections on living with inflammatory bowel disease.

Happy first birthday, Wrestling the Octopus IBD!

During this year, we have spoken with fellow patients and also healthcare professionals to further patient education on Crohn's disease and ulcerative colitis.

We are indebted to all our guests for donating their time so generously, but also to all of you, our listeners, for your supportive comments as we bring our patient experience to the podcast airwaves.

In this episode, Nigel and I reflect on our first year of podcasting - with a few conversation tangents thrown in for good measure!

Hope you enjoy listening...

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The fear of developing colorectal cancer (CRC) when living with inflammatory bowel disease can weigh heavily on our minds as patients.

So Nigel and I resolved to get an expert guest on the podcast who could talk us (and our patient listeners) through the risks and how we can minimise them when living with Crohn's disease or ulcerative colitis.

Enter Professor James East! Prof East is a consultant gastroenterologist at the John Radcliffe Hospital in Oxford, UK and lead author of the British Society of Gastroenterology's updated guidelines.

Here's a summary of what we discussed in this episode:

GOOD NEWS FIRST
• Bowel cancer risk in IBD has fallen dramatically over the past 20 years
• Current risk: 1.4–1.7 times the general population (much lower than older estimates)
• In numbers: 75 in 1,000 IBD patients vs 50 in 1,000 general population

KEY RISK FACTORS
• Inflammation severity and disease extent (biggest drivers)
• "Smouldering" inflammation counts—even without symptoms
• Family history of bowel cancer (first-degree relative)
• Post-inflammatory polyps (markers of past severe inflammation)
• Primary sclerosing cholangitis (PSC)—annual surveillance needed from diagnosis
• Most patients start surveillance 8 years after symptom onset

YOUR MEDICATIONS PROTECT YOU
• Mesalazine and biologics (especially anti-TNFs) reduce cancer risk
• Benefits of controlling inflammation outweigh theoretical immune concerns
• Keep taking your treatment

SURVEILLANCE COLONOSCOPY
• Frequency: every 1–3 years depending on individual risk
• Well-controlled disease: may only need every 10 years
• First surveillance: typically 8 years after symptom onset (earlier with PSC or severe early disease)

MAKING COLONOSCOPY MORE TOLERABLE
• Lower-volume bowel prep (2 litres or less) now recommended—just as effective
• Options: Moviprep, Plenvu, Citrafleet, Picolax
• Generous sedation recommended for IBD patients
• Propofol deep sedation should be available if needed

LIFESTYLE CHANGES THAT HELP
• Stop smoking
• Maintain healthy weight
• Regular exercise
• Mediterranean-style diet: less red/processed meat, more fish, fruit, vegetables, olive oil

RED FLAGS—SEEK URGENT ADVICE FOR:
• Bleeding without diarrhoea
• Symptoms not responding to usual treatment
• Significant weight loss
• Severe pain or abdominal lump
• Anything that feels different from your normal IBD pattern

FUTURE DEVELOPMENTS
• Stool-based biomarker tests to reduce colonoscopy frequency
• AI technology for detecting precancerous changes
• Genetic tests to guide treatment decisions

Remember: surveillance offers protection and promotes good gut health. Early detection of precancerous changes prevents cancer; early cancer detection means cure is possible.

Nigel and I would like to thank Professor East sincerely for donating his time for the promotion of patient education in this important area.

Here is the link to the online colorectal cancer risk calculator mentioned in the episode: https://ibd-dysplasia-calculator.bmrc.ox.ac.uk/

Here is the link to the British Society of Gastroenterology's updated guidelines on colorectal cancer risk in IBD: https://www.bsg.org.uk/clinical-resource/bsg-guidelines-on-colorectal-surveillance-in-ibd

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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.

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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

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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:

📧

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In episode 23 of Wrestling the Octopus IBD, Nigel and I welcome consultant radiologist, Dr Gauraang Bhatnagar (Frimley Health NHS Foundation Trust) and consultant gastroenterologist, Dr Will Blad (Barts Health Foundation Trust) to our podcast to discuss intestinal ultrasound (IUS) in inflammatory bowel disease.

🩺 Key Discussion Points

1. What is Intestinal Ultrasound (IUS)?

• Non-invasive imaging technique for assessing Crohn's disease and ulcerative colitis
• Performed by gastroenterologists and radiologists.
• Increasingly used in clinics and flare settings to reduce reliance on MRI and colonoscopy.

2. Role Compared to Colonoscopy

• Colonoscopy remains essential for diagnosis and cancer surveillance.
• IUS reduces need for repeated colonoscopies and MRIs.
• Best care comes from combining modalities - no single test is perfect.

3. Preparation

• Minimal prep required (short fast, full bladder).
• Often performed without prep in clinic or inpatient settings.
• Patient-friendly compared to colonoscopy bowel prep.

4. What Does IUS Show?

• Focuses on bowel wall thickness, middle and outer layers and complications outside the bowel.
• Observes bowel in its natural state, unlike MRI or colonoscopy.
• Can detect strictures, narrowings, and motility issues.
• Patients can see images live, strengthening engagement and understanding.

5. Detecting Complex Pathology

• Depth limitations: deeper structures harder to visualize.
• Best practice: baseline imaging with MRI/colonoscopy plus IUS.
• IUS then used for repeat monitoring and treatment adjustments.

6. Empowering IBD Patients

• Patients value seeing their scans in real time.
• Builds trust and strengthens shared decision-making.
• Encourages adherence to treatment when improvements are visible.

7. Monitoring Remission & Flares

• IBD is unpredictable; flares can occur despite remission.
• IUS is well tolerated, cheaper, and acceptable for regular monitoring.
• Helps detect subclinical disease activity early.

8. Duration of IUS

• Acute severe colitis: a few minutes.
• Complex Crohn’s disease: 15–20 minutes.
• Typical clinic use: 5–15 minutes depending on complexity.

9. Expanding IUS in the UK

• Vision: IUS available in every IBD service nationwide.
• Current uptake: limited, mostly in London and radiology departments.
• Need for training, shared expertise, and national coordination.

10. Shared Decision-Making

• Patients feel more connected when they see scans.
• Radiologists gain a more clinical role, motivating patients through visible progress.
• Strengthens collaboration between patients and clinicians.

11. Limitations

• Not suitable for all conditions; CT, MRI, or colonoscopy still required in many cases.
• Obesity and deep pelvic loops can reduce image quality.
• Baseline imaging helps determine which modality is best for ongoing monitoring.

12. Equipment & Technology

• Standard ultrasound machines with specialized probes and optimized settings.
• Recent advances allow greater detail, driving wider adoption of bowel ultrasound.

13. Patient Education & Advocacy

• Need for more patient-facing materials on IUS.
• Collaboration with Crohn’s & Colitis UK, IBD UK, and other societies

Follow Rachel at @bottomlineibd

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Welcome to Episode 22 of Wrestling the Octopus IBD! A reminder of our new email address if you'd like to get in touch: wrestlingtheoctopusibd@gmail.com

In this Crohn’s & Colitis Awareness Week special, Nigel and I take a look in the rear view mirror to ponder our decades of lived experience with inflammatory bowel disease - from treatment and attitudes, to advocacy and patient empowerment, to stress and stigma. And of course, our definition of patient‑centred care. We hope you will find this episode honest, insightful and, above all, hope-giving.

🗝️ Key Themes

• Awareness & Advocacy: The rise of patient ambassadors, charities and campaigns that have helped de‑stigmatise stomas and raise public understanding of Crohn's disease and ulcerative colitis.
• Patient‑Centred Care: How shared decision‑making has evolved from prescriptive medicine to collaborative conversations, while acknowledging ongoing challenges.
• Treatment Journeys: From IV steroids and their long‑term effects to biologics like infliximab - and the growing pipeline of advanced therapies.
• Stress & Coping: Emotional vs. physical stress, survival mechanisms and the importance of self‑compassion.
• Work & Flexibility: How working from home and flexible arrangements can ease daily challenges for patients.
• Language Matters: The role of healthcare professionals in framing stomas and surgery with positive, balanced language.
• Messages to Patients: Nigel emphasises letting go of guilt and keeping a sense of humour, while Rachel encourages education, rounded perspectives, and not sweating the small stuff.

📬 Get Involved

• Email: wrestlingtheoctopusibd@gmail.com
• Twitter/X:
  • Nigel: @Crohnoid
  • Rachel: @BottomLineIBD
• 🔮 Coming Up in 2026
  • Intestinal ultrasound (IUS): is it an alternative to colonoscopy?
  • Conversations with a surgeon about surgery decisions for IBD patients.
  • Complementary medicine in IBD with a Mayo Clinic consultant.
  • Future episodes on IBS in IBD and cardiac health in IBD.

Follow Rachel at @bottomlineibd

Follow Nigel at @crohnoid

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You can now email us at wrestlingtheoctopusibd@gmail.com - we'd love to hear your thoughts, ideas and feedback on our IBD patient podcast! And if you like what you hear, please spread the word to others with an interest in Crohn's disease and ulcerative colitis.

In this specially curated episode - for want of another phrase! - Nigel takes us on his personal and often amusing journey through his A–Z of Crohn’s disease experiences. From bone marrow biopsies to varices, stomas to sedation, he shares the gritty, surreal and occasionally entertaining realities of living with inflammatory bowel disease. For my part, I am the foil to his wit, with commentary, questions and a couple of my own stories - including a mention for my upcoming blog, The Perianal Diaries.

💬 Nigel's Memorable Quotes

• “I woke up mid-gastroscopy, took a photo... and went back to sleep.”
• “When I reveal my stoma, you’ll see a pretty good impression of Mick Jagger.”
• “I’ve made a living out of people assuming I knew more than I do.”

📣 Listener Call-Out

Have you had TPN? Experienced Metronidazole side effects? Got your own stoma story? We’d love to hear from you. 📧 wrestlingtheoctopusibd@gmail.com

Follow Rachel at @bottomlineibd

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