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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.

Follow Rachel at @bottomlineibd

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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