One major challenge in managing patients with Inflammatory Bowel Disease (IBD) is differentiating symptoms or flares with those symptoms due to Irritable Bowel Syndrome (IBS). Constipation, a symptom more frequently associated with IBS, can occur in active IBD flares. In addition, patients with IBD can have related IBS, which makes treating constipation in IBD patients more difficult.
IBS vs. IBD
IBS is considered a functional bowel disorder in which there is an abnormality in bowel function. Unlike IBD, there is no inflammatory destruction of the lining of the gut. Symptoms of IBS include abdominal pain, diarrhea, constipation, or alternating diarrhea and constipation. The cause for IBS is largely unknown, and at this time, is felt to be multifactorial, including genetics factors, environmental triggers, a person’s microbiome (or the gut bacteria present in a person’s intestines), and psychological factors.
Is it a flare-up?
When constipation occurs in a patient with IBD, an IBD flare needs to be differentiated from IBS symptoms because this will affect management. Active Crohn’s disease does not commonly present with constipation. Rather, Crohn’s patients with disease of the small intestines or colon typically experience abdominal pain, bloody diarrhea, and fevers. If a Crohn’s patient is experiencing constipation, this is more likely from associated IBS.
Some patients with Ulcerative Colitis (UC) can present with constipation as a symptom of active disease. Usually, patients with active UC experience an increase in bowel movements, bloody diarrhea, abdominal pain, fecal urgency, and fever. Of patients with UC limited to the rectum, about 25 percent will present with constipation and rectal bleeding.
Certain tests favor constipation resulting from symptoms of IBS rather than active proctitis, including a normal C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cell count (WBC), and platelet count"”all markers of inflammation. Endoscopy, either colonoscopy or flexible sigmoidoscopy, allows for visual evaluation, as well as microscopic evaluation through biopsy, of the colon.
After active IBD has been determined as the cause for constipation, the best way to manage symptoms is to treat the underlying disease. In other words, an attempt is made to induce remission of the disease with steroids (prednisone). Recently, a probiotic called VSL#3 has been shown to induce remission of disease in patients with mild to moderate UC. This probiotic has recently been shown to improve constipation symptoms in patients with constipation predominant IBS, as well.
Treatment options for constipation
When active IBD has been ruled out through testing, regulating bowel movements and alteration in diet are the mainstays of therapy. Fiber supplementation with psyllium-based fiber, such as Metamucil, Citrucel, or Benefiber, can be started at a low dose and slowly increased as needed.
In addition, a polyethylene glycol 3350, or Miralax, can be used to help ease constipation. Both fiber and Miralax need to be taken with plenty of water to maintain adequate hydration so as to not worsen constipation. Avoiding foods that cause constipation is important, and patients should keep a food log to identify foods that result in symptoms.
Open communication is key. If you have IBD and are experiencing constipation, it is important to talk with your gastroenterologist. Treatment varies depending on the cause for constipation, and proper management can ultimately affect disease outcomes.