How to Manage Constipation Associated With Crohn’s Disease

People with Crohn’s disease often deal with diarrhea. Though not as common, constipation does occur and may signal an underlying problem.

A person is considered to be constipated if they:

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

Not being able to “go” is common. About 52 million people, or nearly 16 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 or eating enough dietary fiber, or they’re taking certain medications,” says Justin L. Sewell, MD, a professor of clinical medicine in the 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.”

Here are some possible reasons people with Crohn’s may have constipation.

Strictures

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

“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 and Colitis Foundation. While surgery may be optional for some, 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. A 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.

Even though it seems preferable to cut out a section of the bowel if the stricture is short, Sewell notes, if it’s a long stricture or the patient has already had previous resections, it puts 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 that causes tenesmus, a frequent urge to go to the bathroom even when the 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 ulcerative colitis, but it could occur in people with Crohn’s,” says Sewell.

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

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

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 such as 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 water and dietary fiber intake or using stool softeners or stimulant laxatives.

Can Diet Help Prevent or Relieve Constipation?

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

A variety of diets have been used to help manage Crohn’s symptoms or maintain remission, but there is no one tried-and-true diet that works for constipation.

“Getting enough fluids, including fiber in the diet, such as soluble fiber like fruits, vegetables, and whole grains, or taking fiber supplements could help,” says Adam Cheifetz, MD, director of the center for inflammatory bowel disease at Beth Israel Deaconess Medical Center in Boston. “An unprocessed healthy diet without a lot of additives is key,” he says.

Increasing fiber should be gradual, cautions Kelly Kennedy, RDN, Everyday Health staff nutritionist, to prevent gas 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. And during a Crohn’s flare, patients should limit fiber intake and replace it with foods like white pasta and white rice, even though they are considered to be processed foods. When the flare is over, they can return to gradually increasing fiber intake, Kennedy says.

For people with significant strictures, a low-residue diet may be recommended. If effective it 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. (Patients should always get an okay from their doctor first.)

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. However, more research is needed. A recent study found the effects of probiotics inconclusive. While they can’t hurt, the American College of Gastroenterology does not recommend them outside of a trial. You can find probiotics in yogurt that contains live and active cultures or in supplement form.

“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.

“I’ve used probiotics in patients who have underlying [irritable bowel syndrome] symptoms,” Cheifetz says. “It’s been helpful, especially for those who deal with bloating.”

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