Diarrhoea and Constipation
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Diarrhoea and Constipation Edition 4 – June 2015
Improving life for
people affected
Crohn's and Colitis UK Information Sheet by inflammatory
bowel diseases
Diarrhoea and Constipation
Introduction
When we eat, food passes down the
Diarrhoea is one of the main symptoms of
oesophagus (gullet) and then into the
Inflammatory Bowel Disease (IBD), which
stomach, where it is broken down by
includes Crohn’s Disease and Ulcerative
gastric (stomach) juices to a porridge-like
Colitis (UC). Microscopic Colitis, another
consistency.
form of IBD, can also cause diarrhoea.
IBD treatment aims to control the
symptoms and keep you in remission. Yet
some people with IBD continue to have
diarrhoea. This leaflet looks at why this
might happen and includes some
suggestions about ways to help reduce
and manage diarrhoea.
Some people with IBD may experience
constipation. This leaflet looks at the
causes of constipation, and how you may
be able to alleviate it.
What is diarrhoea?
Diarrhoea is generally defined as passing
loose watery stools (faeces, poo) at least
3 times a day. There is often a feeling of
‘urgency’, a need to rush to the toilet.
Sometimes the diarrhoea can be
explosive. It may also lead to bowel The partly digested food then moves into
incontinence with a leakage of faeces. the small intestine where most of the
nutrients are absorbed.
If the diarrhoea lasts less than four weeks,
it is usually referred to as ‘acute The waste, now a watery slurry, passes
diarrhoea’. If it lasts for four weeks or into the colon. It is here that most of the
more, it is generally thought of as ‘chronic’ water is normally absorbed so the waste
(ongoing) diarrhoea. can form solid stools (faeces). These
collect in the last part of the colon and the
Diarrhoea happens when the colon (large rectum and are passed out of the body in
intestine or large bowel) cannot absorb all a bowel movement.
the fluid produced during the digestive
process. Diarrhoea is a common symptom of IBD
affecting the large bowel. During a flare-
As shown in the diagram, the up, the cells in the lining of the colon
gastrointestinal (digestive) tract is a long become inflamed and do not work
tube that starts at the mouth and ends at properly. The colon cannot absorb all the
the anus. fluid and the stools remain loose and
watery, or even entirely liquid – and this is
experienced as diarrhoea.
Crohn’s and Colitis UK, 4 Beaumont House, Sutton Road, St Albans, Hertfordshire AL1 5HH
Information Service: 0845 130 2233 Email: enquiries@crohnsandcolitis.org.uk Website: www.crohnsandcolitis.org.uk
Charity registered in England and Wales Number 1117148 and in Scotland Number SC038632
A company limited by guarantee in England: Company number 5973370Diarrhoea and Constipation Edition 4 – June 2015
The looser faeces can also move more However, if part of the ileum is lost,
rapidly through the colon, causing more much higher levels of bile salts can
frequent bowel movements. drain into the colon. This can irritate
the colon causing watery diarrhoea.
What causes diarrhoea? Inflammation of the end of the ileum
If you have IBD, your diarrhoea may be can also lead to bile salt diarrhoea as
due to a flare-up of your disease - well as to poor fat absorption (see
although there are also some other factors below).
which may be causing the diarrhoea or
making it worse. Malabsorption of fats - If you have
Crohn’s in the ileum (the lower part of
Side effects of drugs for IBD - One of the small intestine) you may have
the rare side effects of 5-ASAs such as difficulty absorbing fats. This can lead
mesalazine and sulphasalazine, is to urgency and to pale and bad
watery diarrhoea. You may be able to smelling, poorly formed faeces that are
reduce this side effect by taking the difficult to flush away.
tablets with or after food. Some of the
immunosuppressants, such as Iron Supplements - You may be
azathioprine and methotrexate, can prescribed iron supplements for
also cause diarrhoea especially during anaemia caused by your IBD. A
the early weeks of treatment. Talk to change in bowel habit is a common
your doctor or IBD team about ways to side effect of iron supplements and
manage this, or see our Drug while some people get constipation,
Treatment leaflets, Azathioprine and others get diarrhoea.
Methotrexate, for further information.
Irritable Bowel Syndrome (IBS) - IBS
Side effects of other drugs - You may is sometimes confused with
also find it helpful to check whether Inflammatory Bowel Disease, but is a
diarrhoea is a side effect of any other separate and different condition. Some
medications you are taking. Antibiotics of the typical symptoms of IBS, such as
and acid-lowering treatments, such as diarrhoea and colicky pain, can be very
omeprazole and lansoprazole, can also similar to those of IBD, but IBS does
cause diarrhoea. not cause inflammation or bleeding.
However, it is possible that some
Colectomy and ileo-rectal people with Ulcerative Colitis or Crohn’s
anastomosis - In this operation the Disease may have irritable bowel
colon is removed and the ileum (the symptoms as well as IBD – probably
lower part of the small intestine) is because the inflammation has
joined directly to the rectum. After this temporarily affected the nerve endings
procedure, your faeces will tend to be in the bowel. So they may, for
much more liquid because you no example, continue to experience
longer have a colon to absorb the diarrhoea following an IBD flare-up,
water. even when the inflammation has died
down.
Small bowel surgery for Crohn’s
Disease - If you have had the end of
the ileum (the lower part of the small
intestine) removed, you may have bile
salt diarrhoea. Bile salts are produced
in the liver and are usually reabsorbed
in the ileum, so that only very small
amounts enter the colon.
2Diarrhoea and Constipation Edition 4 – June 2015
Diet and food sensitivities - Some Antidiarrhoeal drugs - Antidiarrhoeals
people are sensitive to particular foods, work by slowing down the contractions
such as milk and wheat. Too much (muscle movements) of the gut, so that
fibre, spicy food, chocolate, caffeine (in the food takes longer to pass through
coffee, tea and cola drinks), alcohol, your system. This allows more time for
fructose (a sugar in fruit) and artificial the water to be reabsorbed and for the
sweeteners (sorbitol) can all have a stools to become firmer and less
laxative effect, stimulating and urgent, but should generally
loosening the bowels. Intolerance to be avoided if your large bowel is
lactose, a natural sugar found in milk, affected by your IBD (see below).
can cause diarrhoea. If you are Loperamide (Imodium, Arret) is a
concerned about diet and food commonly used and effective
sensitivities, ask your IBD team to refer antidiarrhoeal drug. It is long-acting
you to a dietitian. and usually only needs to be taken
once or twice a day, although it can be
Infections - In people without IBD, taken more often if needed. Other
diarrhoea can often be a sign of: antidiarrhoeals such as diphenoxylate
(Lomotil) and codeine may need to be
gastroenteritis – an infection of the taken three or four times a day.
large bowel, commonly caused by The patient information leaflets that
a virus or bacteria or, come with all antidiarrhoeals advise
against taking them if you have IBD,
Clostridium difficile (also known as
particularly if you are having a flare-up
C. diff) – a type of bacterial
of UC. This is because there are risks
infection that can affect the
of side effects, including toxic
digestive system.
megacolon (when digestive gases get
trapped in the colon, making it swell
These infections can also affect people
up) associated with taking these drugs.
with IBD and your doctor or IBD team
So, whichever condition you have, if
may carry out tests to make sure your
you are having an acute or severe
diarrhoea is not at least partly due to
flare-up, do not take any antidiarrhoeal
such infections.
medicines without first checking with
your doctor or IBD team.
What treatment can I take?
Drugs used to treat active IBD – A
range of drugs are used to treat IBD
Antispasmodic drugs - These work
by relaxing the intestinal muscles to
and then to help maintain remission
slow down bowel movements in a way
once it is under control. If you are on
that not only helps to relieve diarrhoea,
such medication, you should find your
but also the cramping pain often
diarrhoea lessens as the drugs
accompanying diarrhoea. Brands
prescribed for your IBD take effect.
include Buscopan and Colofac. They
Some drugs, such as 5-ASAs and
are usually safe to take, but check with
steroids, tend to act quickly while
your doctor first.
others, such as azathioprine and
methotrexate, take much longer to
work. As mentioned earlier, some Bile salt drugs - These include
people may get diarrhoea as a side colestyramine (Questran) and
effect of these medications. If you do colestipol (Colestid) which come in
continue to have a flare-up or to powder or granule form, and a newer
experience serious diarrhoea, you may drug, colesevelam, which comes as
need to change your medication. Talk tablets.
to your specialist about this.
3Diarrhoea and Constipation Edition 4 – June 2015
These bile salt drugs absorb the Eating
overflow bile salts, preventing them Eat small, frequent meals.
reaching the colon and causing Keep a food diary and note down any
diarrhoea. They can affect the foods that seem to upset you, so you
absorption of other drugs that you may can avoid them. However, it is not
be taking for your IBD. If you are advisable to cut out too many food
taking other drugs, it is worth checking groups, and if you find you are
with your IBD team whether they will avoiding many different types of food,
be affected by the bile salt drugs, and it may be helpful to consult a dietitian
if so, how you can manage taking both. to help you balance your diet.
There is also an alternative ‘lite’ Some sensitivities might be only
version of colestyramine available, but temporary and you may be able to re-
this can cause these side effects too. introduce that food at a later date. If
If you are taking colestyramine and your diarrhoea is worse after you have
have experienced side effects, it may eaten foods containing gluten (a
be worth asking if you can try the lite protein found in wheat, barley and rye)
version as in some people this causes it may be due to an intolerance to
fewer side effects. gluten. But it could also be a sign of
coeliac disease. This is a condition in
Bulking agents - Bulking agents or which the immune system mistakes
‘bulk formers’ are made from a type of substances found inside gluten as a
plant fibre (usually ispaghula or threat to the body and attacks them.
sterculia). Popular brands include This damages the surface of the small
Fybogel and Isogel. These come as bowel (intestines) disrupting the body's
granules which, when taken with plenty ability to absorb nutrients from food.
of water, swell up inside the bowel, There are tests to diagnose coeliac
thickening liquid stools or softening disease. If you are concerned that
hard stools and so providing the bulk foods containing gluten are affecting
needed for the bowel to work more you, speak to your IBD team to see if
normally. Bulking agents can be they can refer you to a dietitian.
useful for both diarrhoea and For many people, foods rich in fibre
constipation. They are generally safe tend to make diarrhoea worse. Don’t
for people with IBD, although they may give up all fruit and vegetables, but try
cause bloating and wind, but should be cutting down on high fibre foods such
avoided if you have a stricture as bran cereal, pulses (peas and
(narrowing) of the bowel, as beans) and the type of fruits or
sometimes happens with Crohn’s vegetables usually eaten with the
Disease. skins, pips and seeds. Onions can be
particularly troublesome.
You can find further information on all Avoid hot or spicy foods, if they don’t
these types of drugs in our booklet Drugs agree with you.
used in IBD and our individual drug If milk makes your diarrhoea worse, try
treatment information sheets. using a lactose free milk and avoiding
foods made with milk such as custards
Can changing what I eat and drink and sauces. Some medicines also
help? contain lactose, but do not stop taking
You may find that you have diarrhoea any prescribed medication without
whatever you eat or drink, but some checking with your IBD team.
people find altering their diet helps to Chicken and rice soup is a traditional
reduce diarrhoea. Everyone is different remedy for diarrhoea, which some
and what works for others may not work people have found useful.
for you. However, the following
suggestions may be of some assistance.
4Diarrhoea and Constipation Edition 4 – June 2015
Carrot soup is also said to be soothing Use moist toilet paper, damp cotton
for the gut, and is rich in beta-carotene wool, or moist toilet wipes. Many baby
which may promote healing. wipes contain alcohol and are best
The BRAT diet, (bananas, rice, avoided, although there are now some
applesauce and toast – or tea) is also ‘alcohol-free’ brands.
traditionally recommended as a way of
reducing acute diarrhoea. But this Whenever possible wash around the
does not contain enough nutrients to anus after a bowel movement. A bidet
be a healthy long term option. is ideal, but you could also use a
shower attachment while sitting with
Other ‘special diets’ may also reduce your bottom over the edge of the bath.
diarrhoea. However, in order to make Or use a soft disposable cloth with
sure that you are still getting a balanced warm water. Avoid flannels and
and nutritious intake, these are best used sponges as they can be rough and are
only with the advice of a qualified dietitian. difficult to keep clean.
Drinking Use non-scented soap or a special
Many people are sensitive to caffeine, washing solution. There are products
so try opting for decaffeinated coffee, specifically developed for people with
tea, and cola drinks. bowel problems. Ask your nurse about
Reduce your consumption of alcohol, these or contact the Bladder and
particularly beer and lager, as this is Bowel Foundation for more
known to have a laxative effect. information. Avoid using antiseptics or
Drinks made with artificial sweeteners disinfectants in washing water, as
can also cause diarrhoea. these can sting.
For more information on healthy eating Dry the area very gently, patting with
with IBD see our booklet, Food and IBD. soft toilet paper or soft towel. Do not
rub. If you are very sore you could use
What should I do about the other a hairdryer on a low setting.
symptoms which may come with
diarrhoea? Use a barrier cream or ointment a little
If you have diarrhoea, you will lose more at a time and rub it in gently. Large
water than usual with your stools. It is amounts stop the skin from breathing
therefore especially important if you have and can make the area sweaty and
IBD that you drink plenty of fluids. You uncomfortable. Make sure the old
may also need to replace the salts and layer of cream is washed off before
sugars lost with the diarrhoea. One way applying more. Choose a simple
to do this is to drink a commercial product such as zinc and castor oil. It
rehydration solution such as Dioralyte, is better to avoid creams containing
Electrolade or Rehydrit. lanolin, as some people are allergic to
this. Other products you could try
For more serious dehydration your doctor include Sudocrem, Cavilon, and
may recommend drinking an Oral Metanium.
Rehydration Solution (ORS) with a higher
sodium (salt) level. For more details on Some people have found alternative
this and how to avoid and manage products helpful, including aloe vera
dehydration, see our information sheet, gel, Kamillosan Baby Cream and
Dehydration. Germoline.
How can I treat sore skin? Try to allow the air to get to the anal
Frequent diarrhoea and wiping can irritate area for at least part of every day.
the skin around the anus, making it sore.
The following tips may help.
5Diarrhoea and Constipation Edition 4 – June 2015
Try not to scratch the anal area, as this occur in Crohn’s Disease (see How
will make things worse. If you find you can I treat constipation?)
are scratching in your sleep, you could
wear cotton gloves in bed (available Not enough fluids - If you are not
from your chemist). drinking enough, this can lead to
constipation as the stools become
If you use a pad for incontinence, hard, dry and difficult to pass.
make sure that the pad has a soft
surface and that no plastic comes into Drugs - As mentioned before,
contact with your skin. constipation can be a side effect of
drugs, for example, anti-diarrhoeals
Wear cotton underwear to allow the or codeine, which is found in some
skin to breathe. Avoid tight jeans and pain killers.
other clothes that might rub the area.
If you wear tights, think about changing Damage to the anal muscles - A
to stockings or crotchless tights. common cause of constipation in
women following vaginal childbirth
If you continue to feel sore, or if your skin or pelvic surgery. A special test
is broken, talk to your doctor, nurse, or may be used to diagnose this.
IBD team. They may be able to prescribe
more effective medications. If the How can I treat constipation?
soreness persists you may have a fungal You may find that drinking plenty of fluids
infection (such as thrush), which will might help form softer stools which are
require different treatment. easier to pass. It may also help to
increase the amount of fibre in your diet,
What is constipation? although this might not work for all people,
Constipation can be defined as passing for example, those with strictures. Some
stools fewer than 3 times per week, people may find that bulking agents, such
needing to strain, or passing hard stools as Fybogel or Isogel, can soften hard
which are unusually large or small. You stools, but also may not be suitable if you
may find that a stool passing through an have a stricture. If you can, increase the
area of inflammation in the colon can be amount of exercise you do to help with
particularly painful. constipation and to speed the passage of
stools through your colon.
What causes constipation?
Proctitis - You may be more likely Laxatives can help to relieve constipation.
to have constipation if you have Osmotic laxatives, such as Movicol, are
proctitis (inflammation of the usually considered the best type of
rectum). laxative for people with IBD. These
increase the amount of water in the large
IBS - Some people with IBD bowel so that stools can be passed more
experience IBS symptoms, which easily. However, laxatives can also cause
can be constipation and/or wind and stomach cramps, especially at
diarrhoea. the start of treatment.
Low fibre diet - Fibre helps stools If you are worried about constipation and
pass through the gut, so if you have how to treat it, speak to your IBD team or
reduced your intake of fibre, you doctor.
may find that you become
constipated. Although excess fibre
should be avoided if you have a
stricture of your intestine, as can
6Diarrhoea and Constipation Edition 4 – June 2015
What other symptoms may come with Help and support from Crohn's and
constipation? Colitis UK
Some people with constipation may All our information sheets and booklets
develop associated conditions such as are available to download from our
haemorrhoids (also known as ‘piles’). website: www.crohnsandcolitis.org.uk. If
Haemorrhoids are swellings that contain you would like a printed copy, please
enlarged blood vessels that are found contact our information line – details
inside or around the rectum and anus. below.
Symptoms can include:
Crohn’s and Colitis UK Information
bleeding after passing a stool Line: 0845 130 2233: Open Monday to
itchiness around the anus Friday, 9am to 5pm, excluding English
a lump hanging down outside of the bank holidays. An answer phone and
anus, which may need to be call back service operates outside these
pushed back in after passing a hours. You can also contact the service
stool. by email info@crohnsandcolitis.org.uk or
letter (addressed to our St Albans office).
Initial treatments for haemorrhoids, if Trained Information Officers provide
caused by constipation, are drinking callers with clear and balanced
plenty of fluids, and increasing the fibre in information on a wide range of issues
your diet. Although these may not be relating to IBD.
suitable for everyone, particularly those
with strictures (see earlier How can I treat Crohn’s and Colitis Support: 0845 130
constipation?) If these steps don’t work, 3344: Open Monday to Friday, 1 pm to
you may need to be referred to a 3.30 pm and 6.30 pm to 9 pm, excluding
specialist for further treatment. If you are English bank holidays. This is a
concerned that you may have confidential, supportive listening service,
haemorrhoids, speak to your IBD team which is provided by trained volunteers
about it. and available to anyone affected by IBD.
These volunteers are skilled in providing
Impact of having diarrhoea and emotional support to anyone who needs a
constipation on everyday life safe place to talk about living with IBD.
Many people with IBD can feel
embarrassed and upset about having Other support from Crohn’s and Colitis
diarrhoea and constipation. But if your UK
symptoms are making you feel this way, Crohn’s and Colitis UK Forum
you might find that talking about it helps. This closed-group community on
You may wish to talk to a professional Facebook is for everyone affected by IBD.
counsellor (see our information sheet You can share your experiences and
Counselling and IBD). Or you may want receive support from others at:
to speak to someone who understands www.facebook.com/groups/CCUKforum
what it’s like to have IBD. Our confidential
listening service, Crohn’s and Colitis Other Organisations
Support, is run by volunteers who have Disability Rights UK
experience of IBD and are trained in 12 City Forum, 250 City Road, London,
giving emotional support (see Help and EC1V 8AF
Support from Crohn’s and Colitis UK). Website: www.disabilityrightsuk.org
From this organisation, you can purchase
You might also find it reassuring to speak RADAR keys which allow access to
to other people with IBD and share specially adapted toilets.
experiences through the Crohn’s and
Colitis UK Facebook Forum.
See Other Support from Crohn’s and
Colitis UK for more details on the Forum.
7Diarrhoea and Constipation Edition 4 – June 2015
Irritable Bowel Syndrome Network (The
IBS Network)
Unit 1.12 SOAR Works, 14 Knutton Road,
Sheffield, S5 9NU
0114 272 3253
Email: info@theibsnetwork.org
Website: www.theibsnetwork.org
The IBS Network is an independent, self
help organisation for people with Irritable
Bowel Syndrome. The helpline is staffed
by specialist IBS nurses.
Crohn’s and Colitis UK 2015
Diarrhoea and Constipation – Edition 4
Last review: June 2015
Next planned review: 2017
Crohn's and Colitis UK publications are
research based and produced in consultation
with patients, medical advisers and other
health or associated professionals. They are
prepared as general information on a subject
and are not intended to replace specific
advice from your own doctor or any other
professional. Crohn's and Colitis UK does not
endorse or recommend any products
mentioned.
Crohn's and Colitis UK is an accredited
member of the Information Standard scheme
for Health and Social care information
producers.
We hope that you have found this leaflet
helpful and relevant. If you would like more
information about the sources of evidence on
which it is based, or details of any conflicts of
interest, or if you have any comments or
suggestions for improvements, please email
the Publications Team at
publications@crohnsandcolitis.org.uk.
You can also write to us at Crohn's and Colitis
UK, 4 Beaumont House, Sutton Road, St
Albans, Herts. AL1 5HH or contact us through
the Information Line: 0845 130 2233.
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