Why bowel symptoms don't always mean our IBD is flaring

“What's the most common non-IBD-related symptom you see in clinic?"

I was asked this question during one of my weekly Instagram Q&As recently, and I received so much feedback about my answer and explanation that I thought I'd share it in a blog too.

My answer?

Bowel symptoms.

That might sound surprising because bowel symptoms are exactly what we associate with Crohn's disease and ulcerative colitis. But let me explain, because this is something I talk about with patients all the time in clinic.

I regularly see people whose inflammation is well controlled, yet they're still experiencing bloating, abdominal discomfort, diarrhoea, constipation or urgency. They're planning their day around the loo or worrying about what they can eat. It can feel confusing and worrying, and understandably so.

Of course, any new or worsening symptoms should always be discussed with your IBD team. It's important to make sure active inflammation isn't the cause. But once that's been assessed (through blood tests, faecal calprotectin, a scope or an MRI), it's worth remembering that bowel symptoms can happen for lots of different reasons, and inflammation is only one of them.

For many people, hearing this is incredibly reassuring. Living with IBD can make us hypervigilant, worrying that every symptom means a flare. Understanding what's actually causing symptoms not only reduces that worry, but also helps us use the right approaches to manage the right problem.

What else could be causing symptoms?

Stress is a good example.

Most of us have experienced a "nervous tummy" before an interview, exam or important event. That's because the brain and the gut are constantly communicating with one another. When we're under stress, that communication changes. The bowel may move food through more quickly or more slowly, become more sensitive, and symptoms such as bloating, pain or urgency can become more noticeable.

That doesn't mean stress is causing inflammation. It means it's changing the way our bowel is functioning, and that can cause symptoms.

Food is another good example.

One of the biggest misconceptions I come across is that if a food causes symptoms, it must be causing inflammation. In reality, that's rarely the case. Food can cause symptoms for lots of other reasons.

For example, as food reaches the large bowel, our gut microbes begin breaking down the parts we don't digest ourselves. During this completely normal process, gases are produced. Some foods naturally produce more gas than others, and some people have more gas-producing microbes than others. For people with IBD, our bowel can sometimes become more sensitive, so that extra gas may lead to bloating, discomfort or changes in bowel habits.

Drinks can have a similar effect. Coffee is a great example. It's a well-known bowel stimulant, which means it encourages the bowel to empty. I often speak to patients who have been told to avoid coffee and assume it's because it causes inflammation, but that's not true. It stimulates bowel movements which, if you're already experiencing diarrhoea or are in a flare, isn't particularly helpful. Again, it's not causing inflammation; it's causing symptoms through a different mechanism.

These are just a couple of examples. There are many others that come up in clinic.

Why getting the cause right is important

Sometimes symptoms are due to active inflammation. In that case, treatment may need reviewing, and dietary advice should be tailored to support active disease.

Sometimes symptoms aren't due to inflammation at all. Instead, we need to understand what's causing them and put the right advice and interventions in place to help reduce them.

Although the symptoms can look very similar, the management can be completely different.

That's why it's so important to understand why symptoms are happening before deciding how best to manage them.

Where does nutrition fit in?

Whether symptoms are caused by inflammation or not, nutrition still has an important role to play.

If inflammation is active, the right dietary advice can help reduce symptoms, reduce the risk of malnutrition, which we know is associated with poorer outcomes in IBD, and make eating feel more manageable and enjoyable.

If symptoms aren't being driven by inflammation, nutrition and lifestyle strategies can often help improve symptoms, quality of life and confidence around food.

Take-home message

If there's one thing I'd like you to remember, it's this:

Symptoms don't always equal inflammation.

Don't ignore new or persistent symptoms, but equally, don't assume every change in your bowels means your IBD is flaring.

Understanding what's causing your symptoms is the first step towards finding the right management. Once we know what's driving the, whether that's inflammation or something else, we can put the right plan in place to help.

If you are looking for sensible, practical, compassionate, evidence-based support with the nutrition side of IBD, I'm here to help.

Through my 1:1 clinic and online courses, I help people with IBD feel more confident around food, reduce symptoms and live a better life with IBD.