Digestive conditions I diagnose and treat

What counts as a change in bowel habit?

Going more or less often than is normal for you, looser or harder stools, new urgency, straining, or a feeling that you have not emptied fully. ‘Normal’ varies widely between people, from three times a day to three times a week. What matters is a lasting change from your own usual pattern.

What are the common causes?

• Infections, which usually settle within a couple of weeks
• Irritable bowel syndrome
• Inflammatory bowel disease and microscopic colitis
• Coeliac disease and bile acid diarrhoea
• Diverticular disease
• Bowel polyps or bowel cancer, which are less common but important to rule out

Which tests will I need?

I do not order every test for everyone. We usually begin with the most informative and least invasive: blood and stool tests. Depending on the results, your age and your symptoms, the next step may be a colonoscopy, a flexible sigmoidoscopy or a scan.

Why do I have ongoing diarrhoea?

Diarrhoea that lasts more than four weeks is called chronic diarrhoea. Alongside IBS, the causes I look for include bile acid diarrhoea, where bile acids are not reabsorbed properly; microscopic colitis, which can only be seen on biopsies; coeliac disease; and inflammatory bowel disease. Each has a specific treatment, which is why reaching the right diagnosis matters.

What can be done about constipation?

Long-standing constipation is common and often improves with the right combination of fluid, fibre, activity and a regular laxative chosen to suit you. I check for contributing causes, such as medicines or a problem with how the pelvic floor muscles coordinate, and can refer you for specialist pelvic floor physiotherapy where that will help.

Should I worry about rectal bleeding?

Bright red blood on the paper is most often caused by haemorrhoids or a small tear called an anal fissure, but that should not be assumed. Bleeding that keeps happening, is mixed in with the stool, or comes with a change in bowel habit, weight loss or anaemia should be assessed. That usually means an examination and a flexible sigmoidoscopy or colonoscopy.

How is IBS diagnosed?

IBS is diagnosed from a typical pattern of symptoms: abdominal pain linked to opening your bowels, with a change in how often you go or in the form of your stools. A small number of tests rule out conditions that can look similar, such as coeliac disease and inflammatory bowel disease. If you are younger, have typical symptoms and these tests are normal, a colonoscopy is often not needed.

What treatments help IBS?

• Changes to eating patterns and fibre
• Medicines matched to your main symptom
• Low-dose medicines that calm the nerve signals between gut and brain
• Gut-directed psychological therapies, including cognitive behavioural therapy and hypnotherapy

Most people need a combination, adjusted over time.

Why am I so bloated?

Bloating is one of the most common gut symptoms. It is often part of IBS or constipation, can be related to how certain carbohydrates are digested, and is occasionally a sign of coeliac disease. We look at your diet, your bowel pattern and a few targeted tests before deciding on treatment.

I already have a diagnosis of IBS. Can you still help?

Yes. Many people I see have tried one or two treatments without much benefit. I review what has been tried, check that nothing has been missed, and build a structured plan, so that you have several tools to use rather than one.

What is inflammatory bowel disease?

Inflammatory bowel disease (IBD) is a group of long-term conditions in which the immune system causes inflammation in the gut. Ulcerative colitis affects the lining of the large bowel, starting at the rectum. Crohn’s disease can affect any part of the gut, most often the end of the small bowel and the colon. IBD is not the same as irritable bowel syndrome (IBS), although some symptoms overlap.

Which symptoms should be checked?

• Persistent diarrhoea, especially with blood or mucus
• Urgency, or waking at night to open your bowels
• Abdominal pain or cramps
• Unintended weight loss
• Tiredness or anaemia

These symptoms have many possible causes, and most people who have them do not have IBD. Simple tests usually show whether further investigation is needed.

How is IBD diagnosed?

There is no single test. I start with your history and an examination, then blood tests and a stool test called faecal calprotectin, which detects inflammation in the bowel. If these point towards IBD, a colonoscopy with biopsies confirms the diagnosis and shows how much of the bowel is affected. A scan of the small bowel, such as an MRI, is sometimes needed as well.

What treatments are available?

Treatment depends on the type of IBD, where it is and how active it is. The aim is more than feeling better: it is to heal the bowel lining and keep it healed.

Can I see you for a second opinion?

Yes. Many people I see already have a diagnosis and want a fresh look at symptoms that are not controlled, side effects, or a decision about starting or changing treatment. Please bring your clinic letters, endoscopy reports and recent results. As a principal investigator for IBD clinical trials I keep closely up to date with newer treatments, and can explain where they might fit for you.

Does diet matter in IBD?

There is no single diet that suits everyone with IBD, but nutrition matters. Flares can lead to weight loss and to low iron, vitamin B12 or vitamin D, and some people with Crohn’s disease benefit from a liquid diet used as a treatment. I lead a hospital nutrition service in my NHS practice, so advice on eating well with IBD is part of the consultation.

What causes acid reflux?

Reflux happens when stomach contents travel back up into the oesophagus (food pipe), usually because the valve at its lower end relaxes too easily. Typical symptoms are heartburn, an acid taste in the mouth and discomfort after eating.

Do I need a gastroscopy?

Not always. If your symptoms are typical and settle with treatment, a camera test is often unnecessary. I would recommend one if you have:

• Difficulty or pain when swallowing
• Unintended weight loss
• Persistent vomiting
• Anaemia or signs of bleeding
• Symptoms that continue despite treatment
• New symptoms from the age of 55

How are reflux and indigestion treated?

• Practical changes to meals, weight, alcohol and smoking
• Antacids and alginates for occasional symptoms
• Acid-suppressing medicines (proton pump inhibitors) at the lowest dose that controls your symptoms
• Testing for and treating Helicobacter pylori
• Referral to a surgeon to discuss anti-reflux surgery, in selected cases

What is Helicobacter pylori?

Helicobacter pylori is a common bacterium that lives in the lining of the stomach. Many people never have symptoms, but it can cause indigestion and ulcers in the stomach or duodenum. It is diagnosed with a breath test, a stool test or a biopsy taken at gastroscopy, and treated with a short course of antibiotics combined with an acid-suppressing medicine.

What is coeliac disease?

Coeliac disease is an autoimmune condition in which gluten, a protein in wheat, barley and rye, causes the immune system to damage the lining of the small bowel. It affects around 1 in 100 people, many of whom have not been diagnosed. Symptoms range from diarrhoea and bloating to tiredness, anaemia or mouth ulcers, and some people have no gut symptoms at all.

How is coeliac disease diagnosed?

The first step is a blood test for coeliac antibodies. The diagnosis is then usually confirmed with a gastroscopy, during which small biopsies are taken from the small bowel. It is important to keep eating gluten until testing is complete: cutting it out beforehand can make both tests falsely normal.

What happens after a diagnosis?

Treatment is a lifelong gluten-free diet, with support from a specialist dietitian. I check for and correct low iron, folate, vitamin B12 and vitamin D, assess your bone health, and arrange follow-up to make sure the bowel is recovering. If symptoms continue despite a careful diet, we look for the reason.

Can you help with weight loss and nutritional problems?

Yes. In my NHS practice I lead the nutrition service at Hammersmith Hospital, and my interests include intestinal failure and short bowel syndrome. Privately I see adults whose gut condition is affecting their weight or nutrition, to find the cause, correct deficiencies and plan nutritional support with a dietitian.