What to Do in a Flare-Up

A flare-up (or relapse) is a period when inflammatory bowel disease (IBD) becomes active again after being quiet. Most people with Crohn’s disease (CD) or ulcerative colitis (UC) have flare-ups from time to time, even when they take their treatment carefully. The most important thing is to act early: a flare-up treated promptly usually settles more quickly and is less likely to become severe.

How do I know it is a flare-up?

The symptoms are usually similar to those you had when you were first diagnosed. They may include:

• More frequent or looser motions
• Blood or mucus in the motions
• Urgency, or needing to get up at night to open your bowels
• Abdominal pain or cramps
• Tiredness, poor appetite or weight loss
• Problems outside the gut, such as painful joints, sore eyes or mouth ulcers

Not every upset is a flare-up. A stomach bug, a course of antibiotics, a change of diet or a new medicine can cause similar symptoms, and irritable bowel symptoms are common in people with IBD. A stool test called faecal calprotectin helps your team to tell whether the bowel is inflamed. See What are the symptoms of IBD?

When to get urgent help

Contact your IBD team the same day, or call NHS 111 out of hours, if you have:

• Severe abdominal pain, or a swollen, tender abdomen
• More than six bloody motions in a day, or heavy bleeding
• A high temperature, a fast heart rate or feeling faint
• Vomiting, especially if you cannot keep fluids down
• Signs of dehydration, such as dizziness or passing very little urine

In an emergency call 999 or go to A&E. A severe flare-up of UC in particular needs treatment in hospital, and delay can be dangerous.

What to do first

1. Contact your IBD nurse or helpline early. Most hospitals have an advice line for people with IBD, and many flare-ups can be managed over the phone without waiting for an appointment. Have a list of your symptoms and medicines ready.
2. Keep taking your usual medicines unless you are told otherwise. Stopping them is a common cause of flare-ups and can make things worse.
3. Provide a stool sample if asked. It will be checked for infection, which can cause or mimic a flare-up, and for calprotectin.
4. Write down what is happening. How many times you open your bowels, whether there is blood, how bad the pain is and how tired you feel. A symptom diary makes this quick and gives your team a clear picture.

How is a flare-up treated?

Treatment depends on which condition you have, where it is and how severe the flare-up is.

• For UC, the dose of mesalazine may be increased, or a suppository or enema added if the disease is in the rectum or lower colon. See Mesalazine.
• A course of steroids, usually over about eight weeks, is often used to settle a moderate flare-up.
• For CD, a liquid diet taken in place of food for a few weeks is an effective alternative to steroids. See Elemental and Polymeric Diets.
• If flare-ups keep happening, your team will usually review your long-term treatment, for example by starting an immunosuppressant or a biologic medicine. See Medicines.
• A severe flare-up may need admission to hospital for steroids given into a vein, fluids and close monitoring.

Looking after yourself

Painkillers

Paracetamol is usually safe. Avoid anti-inflammatory painkillers such as ibuprofen, naproxen and diclofenac, and aspirin for pain, as they can make IBD worse. Codeine and loperamide should only be used on the advice of your doctor, because in a severe flare-up of colitis they can be dangerous.

Eating and drinking

Keep drinking plenty of fluids, especially if you have diarrhoea. Rehydration drinks from the pharmacy can help. Many people find that plain, low-fibre food is easier to manage during a flare-up, but try to keep eating, as the body needs more energy and protein when the gut is inflamed. If you are losing weight, ask to see a dietitian. See Diet in Ulcerative Colitis and Nutritional Therapy.

Rest and work

Rest when you need to, and let your employer or college know early. You can self-certify for the first seven days off work, after which you will need a fit note. See Working with Crohn’s Disease and Colitis.

Stress

A flare-up is stressful, and stress can make symptoms feel worse. Talk to someone you trust, and ask your IBD team about support if you are struggling. See Stress and Inflammatory Bowel Disease.

After a flare-up

Once you are better, think about what may have triggered it, such as missed medicines, an infection, anti-inflammatory painkillers or a stressful period, and discuss with your IBD team whether your treatment should change. For practical ways to reduce the chance of another flare-up, see Preventing a Flare-up of Ulcerative Colitis.

It helps to have a plan ready before the next one. Our free printable flare-up plan, sent when you join our email updates, has space for your IBD team’s contact details, your medicines, your early warning signs and the steps your team has advised.