Crohn’s disease and constipation

How to Manage Constipation Associated With Crohn’s Disease

Constipation can be a sign of a more serious problem. Masterfile

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People with Crohn’s disease often deal with symptoms like diarrhea. Constipation, though not as common, does occur, and it may signal an underlying problem.

You’re considered constipated if you:

  • Have fewer than three bowel movements a week
  • Have to strain to pass stool
  • Are unable to completely empty your bowels.

If you can’t “go,” you’re not alone. About 42 million people, or nearly 15 percent of the American population suffer from constipation, according to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).

“Anyone can develop constipation — most often it’s because they aren’t drinking enough fluids, eating enough dietary fiber, or they’re taking certain medications,” says Justin L. Sewell, MD, MPH, an associate professor of clinical medicine in the UCSF Division of Gastroenterology at the University of California in San Francisco.

“For people with Crohn’s, constipation could mean actual blockage in the intestine,” Dr. Sewell says, “so it’s important to determine if there’s evidence of active disease or inflammation.”

Possible reasons people with Crohn’s may have constipation include:

Strictures For people with Crohn’s, strictures — narrowed areas in the small intestine — can cause abdominal pain, cramping, and vomiting. Strictures can also block food from passing through the digestive tract.

“If there’s a stricture in the bowels, it’s generally managed with medications, or requires surgery to remove a part of the bowel that’s blocking the passage of food,” says Sewell.

In general, 23 to 45 percent of people with ulcerative colitis and up to 75 percent of people with Crohn’s disease will eventually require surgery, according to the Crohn’s & Colitis Foundation. While for some surgery will be optional, others will require it because of complications of the disease.

Small bowel resection, surgery that removes diseased sections of the small intestine, is commonly used to treat strictures. Another, less-invasive alternative is strictureplasty, in which the surgeon makes a lengthwise incision along the narrowed area and then sews it up crosswise, widening the area without removing any portion of the small intestine, thus preserving intestine length.

The procedure is generally safe and effective, but it can cause bleeding in the bowels and fluid leakage from the stitches, and other strictures may form over time.

Sewell notes that though it seems preferable to cut out a section of the bowel if the stricture is short, if it’s a long stricture, or if the patient has already had previous resections putting them at risk of short bowel syndrome, “then perhaps strictureplasty would be more favorable,” he says.

Proctitis Common among people with inflammatory bowel disease (IBD), proctitis is inflammation in the lining of the rectum which causes tenesmus, a frequent urge to go to the bathroom, even though your bowels are empty. There’s generally a feeling of fullness in the rectum and pain during bowel movements.

“This is usually common among patients with UC, but it could occur in people with Crohn’s,” says Sewell.

The cause is rectal inflammation, so keeping an eye on your disease and staying on top of your prescribed medications could help prevent inflammation from worsening and causing tenesmus.

But if the symptom does develop, doctors may prescribe anti-inflammatory topical treatments such as aminosalicylates (5-ASAs), mesalamine, and steroids or biologics.

Fissures An anal fissure is a cut or tear in the anus that typically causes itching, pain and bleeding with bowel movements.

“Since it’s painful, people will often delay going to the bathroom,” says Sewell. “The longer they wait, the harder the stool becomes, which makes it harder for the stool to pass.”

Anal fissures, not to be confused with fistulas, which are abnormal openings that form in the wall of the intestine and connect to other tissues or organs, are usually managed with daily warm sitz baths to clean the affected area and a topical treatment like hydrocortisone. Severe cases often require surgery.

Certain medications Medications such as antidepressants, painkillers, iron supplements, and calcium channel blockers for hypertension and heart disease can cause constipation, too.

If reducing or stopping the medication isn’t an option, Sewell recommends increasing your water and dietary fiber intake, or the use of stool softeners or stimulant laxatives.

Can Diet Help Prevent or Relieve Constipation?

According to the Crohn’s & Colitis Foundation, nutrition is vital to controlling symptoms. Food choices can become more complicated for people with Crohn’s since certain foods may worsen symptoms.

Though a variety of diets have been used to help manage Crohn’s symptoms or maintain remission, there is no “tried and true” diet that works for constipation.

“Getting enough fluids, including fiber in your diet such as soluble fiber like fruits, vegetables, and whole grains, or taking fiber supplements could help,” says Adam Cheifetz, MD, the director of the center for inflammatory bowel disease at Beth Israel Deaconess Medical Center in Boston.

Increasing fiber should be gradual, cautions Kelly Kennedy, RD, a nutritionist for Everyday Health, to prevent gassiness and discomfort.

“Fiber is something that many people with Crohn’s disease limit, so I wouldn’t advise going from 0 to 60, but rather increasing little by little until the desired effects are achieved,” she says.

For people who suffer from significant strictures, the low-residue diet may be recommended. If effective, the low-residue diet would be used for the short-term, until the patient has had surgery, for example, says Dr. Cheifetz.

“The diet helps by preventing high-residue foods that are not digestible, like corn, nuts, skins of fruits, and mushrooms, from getting stuck behind a stricture leading to a small bowel obstruction,” he says.

But before getting on the diet, he recommends getting an okay from your doctor.

The use of probiotics, also called good bacteria, is thought to be good for the gut, and has been linked to positive health outcomes, according to a review published in March 2017 in the journal Nutrients. But more evidence is needed.

“The main limitation at this time is that they haven’t quite figured out which strain(s) and in which amounts might be helpful for a condition such as Crohn’s disease,” Kennedy says.

But Cheifetz says it’s an intervention worth trying as long as your doctor approves.

“I’ve used probiotics in patients who have underlying symptoms,” he says. “It’s been helpful, especially for those who deal with bloating.”

Avoiding foods that worsen or trigger your symptoms, and making sure to follow a well-balanced, nutrient-rich diet is key.

“The only diet I would recommend is a general healthy diet with lots of whole foods and being sure to limit or avoid processed foods, which are low in nutritional value and fiber,” says Kennedy.

Crohn’s Disease

Individuals with Crohn’s may be anemic from a combination of factors, such as chronic blood loss or malabsorption of certain vitamins and minerals. Supplements could help improve this condition, with heme iron polypeptide (Proferrin®) being the preferred choice, due to its quick-acting and low side-effect profiles. Occasionally, a blood transfusion may be necessary.

The most widely prescribed antibiotics are ciprofloxacin (Cipro®) and metronidazole (Flagyl®, Florazole ER®). Broad-spectrum antibiotics are important in treating secondary manifestations of the disease, such as peri-anal abscess and fistulae.

Anti-inflammatory Medication Therapy

There are two goals in the treatment of Crohn’s disease; the first is to eliminate the symptoms (induce clinical remission) and then prevent future disease flare-ups (remission maintenance). To accomplish these goals, physicians aim treatment at controlling intestinal tract inflammation, and the natural consequence of reducing and eliminating inflammation is the reduction and elimination of symptoms. This comes in many forms, using various body systems to effect relief. Your physician may prescribe any of the following medications alone or in combination. It could take some time to find the right mix for you as each case of Crohn’s disease is unique.

5-Aminosalicylic Acid (5-ASA)

These medications are used to reduce inflammation in mild to moderate Crohn’s disease, including mesalamine (Pentasa® and Salofalk®), available orally in the forms of tablets and capsules. Depending on the location of your disease, you may be required to administer mesalamine rectally, in the forms of enemas or suppositories. A combination of 5-ASA and sulfa antibiotic is available orally as sulfasalazine (Salazopyrin®).

Corticosteroids

To reduce inflammation in moderate to severe cases of Crohn’s disease, corticosteroids might help. These are prednisone and budesonide (Entocort®) taken orally, although prednisone tends to have greater side effects. For topical relief of Crohn’s disease in the colon, budesonide (Entocort®) and hydrocortisone (Betnesol®, Cortenema®, Cortifoam®, Proctofoam®) are available in rectal formulations (enemas, foams, and suppositories). In hospital, hydrocortisone (Solu-Cortef®) and methylprednisolone (Solu-Medrol®) can be administered intravenously.

Immunosuppressive Agents

These drugs are used to treat both ileal and colonic Crohn’s and to reduce dependence on steroids; they include azathioprine (Imuran®), cyclosporine, mercaptopurine/6-MP (Purinethol®), and methotrexate sodium (Rheumatrex®). It could take up to 12 weeks or more of therapy to see results.

Biologics

Biologic medications are important treatment options for those who have moderate to severe Crohn’s disease. These products are specially developed antibodies, which selectively block molecules that are involved in the inflammatory process. Gastroenterologists routinely prescribe biologics, which include infliximab (Remicade®), adalimumab (Humira®), golimumab (Simponi®), vedolizumab (Entyvio®), ustekinumab (Stelara®), and most recently, two biosimilars of infliximab (Inflectra®, Renflexis®), to control the symptoms (induce clinical remission) of Crohn’s disease.

Health Canada approved Remicade® in 2001 to induce clinical remission in Crohn’s disease, for ongoing use to maintain clinical remission, for reducing or eliminating corticosteroid use, for healing and closing fistulae, and for healing the lining of the bowel wall (mucosal healing). A biosimilar of infliximab (Inflectra®) was approved in 2016, and another biosimilar of infliximab (Renflexis®) was approved in 2018. Humira®, a fully human monoclonal antibody, was approved in 2006 to induce clinical remission in Crohn’s disease and for ongoing use to maintain clinical remission. Subsequent biologics approved to treat Crohn’s disease are vedolizumab (Entyvio®), and ustekinumab (Stelara®).

Both Humira® and Simponi® are self-administered under the skin (subcutaneously), Humira® every two weeks, and Simponi® every four weeks. A health care professional administers Entyvio®, Inflectra®, Remicade®, Renflexis®, or Stelara® by intravenous (IV) infusion. The treatment intervals might change depending on the medication and the response.

An emerging tool to help physicians be sure that patients are on the right medication at the right dose is Therapeutic Drug Monitoring. This involves laboratory testing to determine the level of the drug in the system and a gastroenterologist assesses this in the context of the patient’s symptoms at specific periods during the treatment schedule.

Surgery

Sometimes a surgeon will remove severely diseased portions of the digestive tract, but this is only as a last alternative, usually in cases where medical management fails and complications arise, such as obstruction, strictures, and fistulae, or abscess formation. An unfortunate feature of Crohn’s disease is that there is a high recurrence rate, even after surgical removal of all visible and microscopic disease. Therefore, it is pragmatic to treat Crohn’s disease with the most effective therapies to prevent these complications. Even though most physicians are slow to recommend surgery, there are times when it will be required. An emerging surgical therapy is intestinal transplantation, but there are barriers yet to overcome, such as tissue rejection and inflammation in the newly transplanted organ.

Crohn’s Disease Outlook

Crohn’s disease is a chronic inflammatory condition manifesting primarily in the digestive tract. Because there is no cure, Crohn’s patients require continuing medical care. Patients must adhere to a proper nutrition and medication regimen, even when things appear to be going well. Your physician will monitor your disease regularly, even during periods of remission.

Want to learn more about Crohn’s disease?

We have several related articles that may be helpful:

  • Infograph
  • Short Bowel Syndrome
  • Biosimilars
  • Survey Results: Biosimilars
  • Biologic Coverage for IBD
  • Therapeutic Drug Monitoring
  • Medical Marijuana and IBD
  • IBD and the Balanced Dinner Plate
  • BadGut® Stories
  • Living with IBD: Tips From Our Support Groups
Image Credit: © bigstockphoto.com/pablopicasso

Constipation and Incomplete Bowel Emptying

Constipation is not a typical symptom of Crohn’s disease.1 Nevertheless, constipation can be a symptom of Crohn’s disease complications.2 It also can be a side effect of medications.

Constipation can be a symptom of ulcerative colitis, particularly in people with left-sided disease, where only the left side of the large intestine is inflamed.3

The medical definition of constipation is in the Table.4 One sign is having 3 or fewer bowel movements per week.1 Straining, hard stool, or abdominal discomfort alone are not constipation. However, having 2 or more of these symptoms at least 25% of the time is a sign of constipation.1

Table. Diagnosis of Chronic Constipation

Patient has 2 or more of the following:

Straining during ≥25% of defecations.

Lumpy or hard stools in ≥25% of defecations.

Sensation of incomplete evacuation for ≥25% of defecations.

Sensation of anorectal obstruction/blockage for ≥25% of defecations.

Manual maneuvers to facilitate at least ≥25% of defecations.

Fewer than 3 defecations per week.

Patient rarely has loose stools without the use of laxatives.

Patient does not meet the criteria for irritable bowel syndrome.

From: ASGE Standards of Practice Committee. Gastrointest Endosc. 2014;80:563-565.

Incomplete bowel emptying is the feeling that you need to pass stool, but your bowels are already empty. If you have this feeling with more than 25% of your bowel movements, it may be a symptom of constipation.1 This feeling can also occur without constipation, as a symptom of inflammation in the colon or rectum. There is more information about incomplete bowel emptying at the end of this article.

What causes constipation in those with ulcerative colitis?

In ulcerative colitis, constipation can occur in people with early stage disease or in people with left-sided disease. While the speed of transit is increased in the inflamed portion, it slows in the non-affected part of the intestines, which may lead to constipation.3

Strictures and anal fissures can also cause constipation, or constipation can be a side effect of medication or supplements.

A stricture is a section of the digestive tract that has become abnormally narrow. A stricture forms when connective tissue builds up within the digestive tract. When this happens, food and waste cannot pass normally.

An anal fissure is a split or tear at the end of the anal canal. Constipation can cause a fissure. A fissure can also make constipation worse. Some fissures are very painful. Having a bowel movement may feel like you are “passing shards of glass.”5 Consequently, you may try to delay a bowel movement, leading to constipation.6

You may need opioid pain relievers after surgery or for abdominal pain. You may take an iron supplement to treat anemia. These can cause constipation.

What are other causes of constipation?

Constipation can be a condition on its own, called primary constipation. Primary constipation can be caused by:7

  • Uncoordinated pelvic muscles, leading to straining.
  • Slow movement of waste through the digestive tract.
  • Normal movement of waste through the digestive tract, but difficulty passing the waste out of the body.

Constipation also can be a symptom of other medical conditions, including:1

  • Depression
  • Diabetes mellitus
  • Hypothyroidism
  • Irritable bowel syndrome
  • Neurologic disorders (problems with the nerves)

How common is constipation?

Constipation is one of the most common digestive tract problems in adults. There are 2.5 million clinic visits per year for constipation.4 In a general population, about 12% of men and 16% of women have constipation.1 Risk factors for constipation are:

  • Female gender
  • Older age
  • Low-calorie, low-fiber diet
  • Using several medications

How is constipation evaluated?

Your health care provider will ask questions about your constipation symptoms. Tell your provider about:1,7,8

  • Abdominal pain or cramping
  • Swelling or bloating
  • Nausea, vomiting
  • Consistency of stool
  • Use of digital manipulation (eg, a lubricated finger) to pass stool
  • Pain while passing stool
  • Medications and laxatives you are taking
  • Typical diet or recent diet changes

These details can help your provider sort out the cause of constipation.

The physical examination will probably include an abdominal and rectal examination.1 A colonoscopy is not a routine procedure for constipation. However, colonoscopy is useful if there are signs of an obstruction.4

How is constipation treated?

Treatment for constipation depends on the underlying cause. For constipation related to left-sided ulcerative colitis, stool bulking agents or laxatives can help.3 For constipation related to inflammatory bowel disease complications, treating the complication may improve bowel function. Small strictures can be treated with endoscopy. Surgery is used to treat large strictures. Most anal fissures heal on their own. While the fissure is healing, there are things you can do at home to ease the pain. Options include topical pain medication and a sitz bath.9

What causes the feeling of incomplete bowel emptying?

You may have had the feeling that you need to pass stools, but your bowels are already empty. The medical term for this is tenesmus. You may also hear it described as a feeling of “incomplete evacuation” or “incomplete bowel emptying.” You may strain when you feel this way, but pass very little stool.

Feeling this sensation is more than 25% of the time is one part of the definition of constipation.1 However, inflammation in the rectum or colon is a more common cause.10 It is a typical symptom of Crohn’s disease, ulcerative colitis, and diversion colitis.11,12 It also can be a symptom of a rectal stricture.9,11

Treating constipation in Crohn’s disease

Treatments include dietary and lifestyle changes, medications, and bowel training. We discuss some of these options below:

Dietary fiber

Consuming more dietary fiber leads to more water absorption in the bowels. This makes stools softer and easier to pass.

Foods rich in fiber include:

  • fresh or dried fruits, such as unpeeled apples and pears, prunes, berries, and oranges
  • fresh or cooked vegetables, such as spinach, carrots, broccoli, sweet potatoes, and unpeeled potatoes
  • legumes, such as lentils, beans, and peas
  • nuts and seeds
  • high-fiber breakfast cereals, which often include bran or whole grains
  • whole-grain breads, pastas, and rice

Speak to a doctor or dietician before making significant dietary changes. People with strictures should not adopt high-fiber diets.

To prevent gas and bloating, it is best to gradually introduce high-fiber foods into the diet.

Fluids

Drinking more fluids can help soften stools and make them easier to pass. Fluids can include:

  • water
  • clear soups
  • fruit and vegetable juices with no added sugar
  • low-sugar sports drinks
  • non-caffeinated beverages

Exercise

Share on PinterestRegular exercise can help support healthy bowel movements.

Getting more exercise can help stools move through the colon more quickly and increase the frequency of bowel movements.

Experts recommend doing at least 30 minutes of aerobic exercise on most days, or about 150 minutes per week. This can involve activities such as cycling, swimming, and brisk walking.

It may not always be easy or possible to exercise when symptoms flare up. Other ways to increase physical activity can include:

  • Taking short walks
  • using the car and elevator less
  • taking regular breaks from desks and computers to walk around and stretch

Laxatives

Laxatives are a short-term option for the treatment of constipation. Longer-term use of these medications can make it difficult for a person to have a bowel movement without taking a laxative.

People with Crohn’s disease should speak to a doctor before trying a laxative.

According to the National Institute of Diabetes and Digestive and Kidney Diseases, the following types of laxatives are available over the counter:

  • osmotic agents, such as milk of magnesia or Miralax
  • bulk-forming agents, such as Citrucel or FiberCon
  • stool softeners, such as Colace or Docusate
  • lubricants, such as mineral oil
  • stimulants, such as Correctol or Dulcolax

Doctors generally only recommend stimulant laxatives for people with severe constipation, or if other treatments have not worked.

Prescription medications

For people with severe or difficult-to-treat constipation, a doctor may prescribe lubiprostone, linaclotide, or plecanatide.

Lubiprostone works by increasing fluid in the large intestine, which helps soften stool and lead to more frequent bowel movements.

Linaclotide and plecanatide can help restore regular bowel movements, but they may take up to 1 week to have an effect. These two medications may cause severe dehydration in some people, and children should not take them.

Doctors need to rule out any intestinal obstructions, such as from strictures, before a person starts taking these medications.

Stopping medications

If a medication is causing a person’s constipation, the doctor may recommend changing, reducing, or stopping the drug or supplement.

Bowel training

Doctors may recommend bowel training for some people with constipation.

This involves trying to have a bowel movement at the same time each day. Bowel training may also include changing the way a person sits on the toilet.

Over time, this can help a person have more regular bowel movements.

Biofeedback therapy

Biofeedback therapy can help treat constipation in people who have problems with their pelvic floor muscles.

It involves using electronic devices to provide feedback on the activity of specific muscles, which allows the person to retrain them and gain better control.

Inflammatory Bowel Disease Clinic

This is one of the most common forms of CD. Typical symptoms are the pain in the lower right side of the abdomen, especially after eating, diarrhea and weight loss. Any bleeding is unlikely to be visible in stools, but stools may appear black and blood tests may show that you are anemic.

​Colonic

Crohn’s Disease in the colon (large intestine or large bowel) is often called Crohn’s Colitis.

This is also a common form of CD, but is not the same as Ulcerative Colitis. The main symptom tends to be diarrhea, with blood and mucus. Because of the inflammation, the colon cannot hold as much waste as normal and you may have very frequent bowel movements, especially if your rectum is inflamed. You may also have urgency to pass stools, and tenesmus (feeling the need to pass a stool although the rectum is empty).

If Crohn’s disease affects both ileum and colon, it is called Crohn’s ileocolitis.

​Small bowel

This type of Crohn’s is also referred to as ileitis or jejunoileitis, depending on the part of the small bowel affected. Abdominal pain and diarrhea are also typical symptoms of Crohn’s in the small bowel, along with nutrient deficiencies. Again, the diarrhea is unlikely to be blood-stained, but you may still have anemia, and also weight loss. The small bowel is commonly affected in children and young people.

​​

Perianal

Crohn’s in the area around the anus (back passage) can occur on its own or at the same time as inflammation in other parts of the body. It is quite common, and some people notice perianal symptoms before they develop intestinal symptoms. It causes a number of symptoms, such as:

  • Fissures – these are tears or splits in the lining of the anal canal (back passage), which can cause pain and bleeding, especially during bowel movements

  • Skin tags – small fleshy growths around the anus

  • Hemorrhoids (piles) – swollen blood vessels in or around the anus and rectum

  • Abscesses – collections of pus that can become swollen and painful. They are often found in the area around the anus and can cause a fever or lead to a fistula.

  • Fistulas – these are narrow tunnels or passageways between the gut and the skin or another organ. In perianal Crohn’s, fistulas often run from the anal canal to the skin around the anus. They appear as tiny openings in the skin that leak pus or sometimes fecal matter. They can irritate the skin and are often sore and painful, but can usually be treated with medication and/ or surgery. For more information see Living with a Fistula.

Gastroduodenal

Crohn’s in the upper gut – the esophagus, stomach or duodenum – is much less common, but may occur on its own or alongside Crohn’s in other parts of the digestive system. Key symptoms include indigestion-like pain, nausea with or without vomiting, loss of appetite, and weight loss and anemia.

Oral Crohn’s

Crohn’s can occasionally affect the mouth. True oral Crohn’s, is often referred to as ‘orofacial granulomatosis’ and is more likely to affect children, although it is rare. It typically causes swollen lips and mouth fissures. Some people with Crohn’s may develop mouth ulcers during flare-ups. This can sometimes be due to nutritional deficiencies such as vitamin B12, folate, and iron.

CAN CROHN’S HAVE COMPLICATIONS WITHIN THE BOWEL?

Crohn’s can sometimes cause complications (extra problems). These may be in the gut itself or can involve other parts of the body. Complications in the gut may include strictures, perforations, and fistulas.

Strictures

Ongoing inflammation and then healing in the bowel may cause scar tissue to form, which can create a narrow section of the bowel. This is known as a stricture. A stricture can make it difficult for food to pass through and, if severe, may cause a blockage (obstruction). Symptoms include severe cramping abdominal pain, nausea, vomiting and constipation. The abdomen may become bloated and distended, and the gut may make loud noises. Strictures are usually treated surgically, often with an operation known as a stricturoplasty. However, in some cases it may be possible to treat them endoscopically with balloon dilatation (see What are the most likely operations for Crohn’s Disease). Some people have ‘inflammatory strictures’, where inflammation, not scar tissue, narrows the intestines. Often, medication can reduce this inflammation.

Perforations

Although rare, inflammation deep in the bowel wall or a severe blockage caused by a stricture may lead to a perforation or rupture of the bowel, making a
hole. The contents of the bowel can leak through the hole. This complication is a medical emergency. Symptoms include severe abdominal pain, fever, nausea, and vomiting. In some cases, the leak will form an abscess.

Fistulas

Some people with Crohn’s may develop a fistula. A fistula is an abnormal channel or passageway connecting one internal organ to another, or to the outside surface of the body. Most fistulas (also called fistulae) start in the wall of the intestine and might connect parts of the bowel to each other, or the bowel to the vagina, bladder, or skin (particularly around the anus). A fistula forms when the inflammation in Crohn’s spreads through the whole thickness of the bowel wall and then continues to tunnel through the layers of other tissues. Fistulas may be treated medically or with surgery. For more details see Living with a Fistula.

CAN CROHN’S DISEASE AFFECT OTHER PARTS OF THE BODY?

Crohn’s disease (CD) can cause complications (extra problems) outside the digestive system. Over a third of people with CD develop other conditions, mainly affecting the joints, eyes and skin. Refer to the Extraintestinal Manifestations section for more information.

You may find helpful information available in the IBD diagnostics, IBD treatment and IBD and lifestyle sections.

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