Diet / Lifestyle
Q. I have had ulcerative colitis for 19 yrs. This past year I was hospitalized twice. I was on prednisone 3 times 8 weeks at a time also. I finished tapering the prednisone 5 weeks ago. I started feeling dizzy and like I'm in a fog and just plain sick. This feeling lasts for most of the day, with the morning being extremely bad. I can't seem to function. My "normal" life is shot. What can cause this feeling?
A. When patients are on corticosteroids the patient’s own adrenal glands that make endogenous steroids do not function. The weaning process is done to allow the body to begin making its own steroids. If this does not happen, patients can become sick. I wonder whether your adrenal glands are not acting properly. See your physician.
Q. Is there a special diet for ulcerative colitis? Are there food items that should be avoided?
A. We recommend a well balanced diet. If the patient is lactose intolerant would recommend lactose free diet otherwise a well balanced diet is recommended.
Check out the CCFA diet brochure at: http://www.ccfa.org/assets/pdfs/diet-nutrition-2013-1.pdf
Q. Are IBD patients every referred to Occupational Therapists. If so, what is typically worked on?
A. We do not usually make use of Occupational Therapists.
Q. I have been told by several people that food grade Diatomaceous Earth can help with my acute Colitis symptoms and was wondering if you had any advice concerning this? I would like to use natural ways of healing if possible. I am willing to try this product if it is safe!
A. There is no data that diatomaceious earth is helpful in colitis and I would not suggest a trial. There is also limited data regarding safety of these agents, and concern about the chemical content in such foods (diatomaceous earth may contain silica).
Q. I’m 36 years old. I have Crohn’s Disease, no insurance and no job due to the severity of the disease. Where can I get help for treatment?
A. The Health Insurance Marketplace is a new way to find quality health coverage in one place. Within the Marketplace you can learn about your health insurance options, compare insurance plans and submit an application. Many people qualify for financial help from the government to help cover the cost of insurance. For more information about the Marketplace or to apply for coverage, visit: www.healthcare.gov . The deadline to sign up is Feb 15th. For free health care you can get services at community health centers. To find centers in your area visit: http://findahealthcenter.hrsa.gov/. Finally is you are unable to work because of your disease, you may be able to apply for social security disability benefits. Contact the Social Security Administration at www.ssa.gov .
Q. Is whey or casein ok to use as a crohns patient? If yes, why and what are the benefits from using it?
A. It's difficult to determine if whey and casein intake have any beneficial effects when dealing with the IBD patient. One research article looked at Crohn's tissue and casein resulting in a significant increase in an anti-inflammatory effect. So, how do we deal with at a practical level?
The major proteins in milk are casein and whey and they're both excellent sources of all the essential amino acids. If a IBD patient is having difficulties with milk products in general, perhaps casein can be an allergen for some individuals. Sometimes, if intolerance is found with milk products, the source of the problem may not be casein or whey, but the natural sugar in milk, lactose. Omitting lactose or choosing lactose free milk products may be a may to omit potential bloating and gas that's often associated with it. High fat milk products also can cause some gastrointestinal upset in some the our patients.
At this time, it appears casein may be somewhat beneficial causing an anti-inflammatory effect in the Crohn's patient. Presently, I recommend finding an abundance of essential amino acids from many different sources, balancing out your diet with healthful, natural and wholesome food choices.
Dig Liver Dis. 2002 Jun;34(6):403-8.
Q. I have Short Bowel Syndrome, malnourished and need eg. form of iron. Which is the best form of iron to use with no ileal-cecal valve?
A. Iron is absorbed in the duodenum (1st part of the small intestines) and should not be greatly affected with short bowel syndrome unless Crohn’s or another factor is impacting absorption in the duodenum or there is a chronic source of blood loss. I would consult with your physician to determine if and how significant is the iron deficiency. There are several formulations of oral iron (ferrous sulfate, ferrous gluconate, and ferrous fumurate) and if oral treatment is not tolerated intravenous iron can also be prescribed.
As for other nutrients that may be low in short gut syndrome due to absence of the end portion of the small intestine and or diarrhea include vitamin deficiencies (B12, A, D, E, K) and mineral deficiencies such as zinc, magnesium and calcium. Please see the Short Gut Syndrome and Crohn’s disease brochure nutrition section for further recommendations.
Q. Is it normal for all your joints to hurt in cold weather? We just moved to WA State from LA. I have Crohn's and I have never hurt so badly.
A. In a subset of patients with rheumatoid arthritis, weather seems to impact on joint symptoms. It’s not clear in the medical literature as to which aspect of weather (barometric pressure, temperature, humidity, solar exposure) is the major driver in the subset of patients that are affected by weather. Although there is a lack of medical studies evaluating if weather plays a part in joint symptoms in inflammatory bowel disease patients, it is certainly possible that weather may be playing a part in your symptoms. I would also recommend seeing your physician to make sure there is not another reason such increased Crohn’s activity or a medication side effect.
Q. Have there been any studies on the use of Aloe Vera in the treatment of Crohn's Disease? Also, if there is any proof as to the benefits of Aloe Vera? What would be the normal dosage?
A. In test tubes, aloe vera gel may also have anti-inflammatory and anti-oxidant effects. Aloe vera in animal studies may reduce inflammation in the ear and synovial (joing) fluid. There have been no studies published assessing aloe vera treatment for Crohn’s. There was a small study of 44 subjects published by Langmead et al (APT, 2004) assessing the effectiveness for treating mild to moderate ulcerative colitis. Forty-six percent of patients receiving aloe vera gel 100mL by mouth twice a day responded compared to 14% receiving placebo after 4 weeks, but remission and endoscopic improvement was not found to significantly different. Larger studies are needed in UC and studies are needed in Crohn’s before it can be recommended as a treatment.
Q. I have UC and had a complete colectomy with an ileostomy bag in 2008. In the same year my surgeon told me I needed to lose a lot of weight to get a reversal. They decided to do a Verticle gastric sleeve (removal of 85% on my stomach cut it away and staple it closed). Since then for whatever reason my body can not break down any fruits, vegetables of any kind and I'm trying to figure out what my body is missing to make this happen. I also have extreme malabsorption issues.
A. Absorption of nutrients occurs in the small intestine, which should not be affected by either surgery that you had. True malabsorption would be marked by weight loss and low protein levels in the blood. There are parts of fruits and vegetables (eg, the outer portion of a corn kernel) that none of us digest or break down (high residue foods), but in people who have formed stool, this particulate matter generally cannot be seen. The fecal matter that comes through the stoma however is liquid to mushy and thus you can see that part of foods that are not digested.
Q. I was recently diagnosed with Crohn’s disease. Is it ok to continue sexual intercourse with my boyfriend?
A. Yes, as long as it’s not painful. We generally advise that patients considering pregnancy are in remission for three months prior to conception attempt; further while most medications are not contraindicated in pregnancy, methotrexate is one that should not be used by women for at least three months preconception or during pregnancy. Thus, appropriate birth control is advised and if pregnancy is a consideration in the future, discussion ahead of time with your gastroenterologist is advised.
Q. As many iron supplements cause constipation, what are some alternative remedies to treat anemia (not including iron infusions)?
A. The first question to answer is what kind of anemia you have (ie, true iron deficiency, B12 deficiency, and “ anemia of chronic disease” are the most commonly seen in IBD). If it's a true iron deficiency, then it's generally from blood loss (even if you can't see blood in stool), not an absorption issue as iron is absorbed high in the small intestine (duodenum) which is an uncommon site for Crohn's in adults (UC involves only the colon or large intestine). In menstruating women, menses may also contribute to iron deficiency. If iron deficiency is from active IBD, then healing the intestine is the best way ultimately to correct this problem. As for supplements, unfortunately, besides oral iron supplements and infusions, blood transfusions would be the only other way to do this.
Q. I want to find a support group for this difficult disease. I do not want an on line support group. I want to sit with others and talk about encouraging and positive ways to cope. Where is CCFA's phone number to talk to a human being about a support group.
A. CCFA has support groups throughout the USA. You can call the IBD Help Center to speak with an Information Specialist at 888 694-8872. You can also find a support group on the website through the local CCFA chapter at http://www.ccfa.org/chapters
Q. How do I get my appetite back during a very painful flare up?
A. Symptoms of abdominal pain, diarrhea, bleeding usually respond first to treatment after flare of IBD. This is then followed by gradual resolution of other symptoms such as fatigue and loss of appetite. The first treatment for loss of appetite is to ensure that the underlying inflammation is being treated adequately. It is also important to ensure that the symptoms are not due to other micronutrient deficiencies like low iron, vitamin D, or vitamin B12 levels. Expanding the diet to foods of interest will be helpful to get appetite back up. Rarely, appetite stimulant medications like marinol may be of help.
Q. What colleges recognize crohns disease?
A. Crohn's disease is a chronic disease and students are protected from discrimination under the American’s with Disability Act and the Rehabilitation Act of 1973. These Acts prohibit discrimination in admissions and recruitment, either by excluding disabled students or by setting a quota for admission of disabled students. Students who need additional support, services or accommodations to maintain their academic performance should contact the College Disability Office for more information.
Q. I have Crohn’s and cannot eat grain and vegetables. I am eating mostly carbs and I am gaining too much weight. What can I do to control the weight but still be able to eat?
A. It is important to eat a balanced diet and avoid too many refined sugars and carbohydrates. As raw fruits and vegetables are often poorly tolerated, it may be helpful to include plenty of well cooked fruits and vegetables. Consider juicing fruits and vegetables – this usually results in less fiber content than raw fruits and vegetables and may help avoid high caloric intake. Consider including high protein foods that have fewer calories than refined carbohydrates. If there is still difficulty, consider consulting with a nutritionist.
Q. I’ve had three ballon dilations in the last 14 months and they usually last 6 months or so. I’ve been on Humira for almost two years with no side effects. I have a stricture that really makes me constipated. My gastro said my intestines are free and clear of any inflammation but it's just the stricture. He said there are no other options except a colostomy? I find that hard to believe. Is he correct? What about anoplasty flap?
A. Crohn’s disease can cause structuring anywhere along the intestinal tract including where the rectum meets the muscles that provide control over bowel motions. A stricture at this level is generally treated with dilatation sometimes in combination with steroid injections into the site. The patient is then encouraged to use products that promote a well-formed stool that acts to dilate the area as it passes through. In rare instances, the stricture can be managed by excising a short area of narrowing and reconnecting the two ends of bowel usually in combination with a temporary ileostomy or colostomy. An anoplasty flap is generally not appropriate because the stricture is not close enough to the skin surrounding the anus to allow such an operation to be successfully performed.
Q. My adult son has Crohns disease. He is a full time student and doesn’t have an income or insurance. His medication is over $1000 per month. We don’t know where to go to get assistance with getting his medication. Any help you provide will greatly be appreciated.
A. For help with finding free and low cost medication check out www.needymeds.org. For a longer term solution, the Health Insurance Marketplace is a new way to find quality health coverage in one place. Within the Marketplace you can learn about your health insurance options, compare insurance plans and submit an application. Qualified Health Plans include ambulatory patient services, hospital coverage, prescriptions drugs and other services. Open enrollment for 2015 coverage begins November 15, 2014. To learn more about health insurance download CCFA’s fact sheet on Health Care Reform http://www.ccfa.org/assets/pdfs/health-reform-2015.pdf or check out www.healthcare.gov.
Q. Do processed foods play a role in the development of Crohn's and Colitis?
A. It is hard to say. Most researchers feel that the microbiome (the bacteria, virus, fungi that make up the gut) drives many inflammatory diseases. This microbiome can change based on diet, antibiotics and other environmental triggers. There are many diets that have been suggested for IBD and they have variable success rates. However, one thing they all seem to have in common is the reduction of processed foods. This is a generally a good thing for everyone. However a clear association has not been shown to date.
Q. I’ve had crohn’s disease for nearly three years. I take azathioprine and have been in remission for more than six months. I have a healthy appetite and eat a healthy diet but I continue to lose weight. What can be contributing to the weight loss?
A. It would be worth checking to make sure there is truly no inflammation even though you feel you are in remission. Sometimes inflammation can be hidden and is detectable by colonoscopy, imaging or fecal calprotectin. If these are negative, having a nutritionist do a calorie count is also worthwhile. Sometimes in changing diets due to Crohn’s disease leads to weight loss due a change in the types of foods consumed.
Q. I've had Crohn's for 17 years and I want to get out more with my family to hike, go to amusement parks and other venues where I might not have immediate access to a rest room. I’m tired of the excuses and limits. I flirted with the "wearing a diaper" just to lessen my anxiety about not being near a bathroom. Do you have suggestions or share with me what I can do in these cases?
A. This question really depends on the specific details of your Crohn’s so check with your doctor to see if these suggestions are right for you. Sometimes you can take an anti-diarrheal prior to going out (loperamide for example) to provide an extra layer of security and control. Sometimes anxiety and fear of these situations can result in more trips to the bathroom and an anti-anxiety medication can be helpful. Finally, make sure there isn’t any active inflammation that can be treated to better control your Crohn’s.
Q. Can you serve in the military with Crohn's?
A. Each branch of the US military has a website (i.e. www.navy.mil; www.army.mil ) that provides information on eligibility requirements and other information such as medical waivers. The military website and your local recruiter may be your best source of information regarding your specific eligibility.
Q. Are puréed raw fruits and vegetables ok to eat for UC?
A. Pureed foods are fine for anyone - even those with UC. The good thing about pureed food is that it's decreases the work of the GI tract to break down the food and allow the nutrients to be absorbed. This may be a great way to receive a more balanced diet when someone is in a GI flare - since the foods are already more easily absorbed
Q. What foods are best to eat and avoid with CD. What is the best way to prepare food and where can I find more information about diet?
A. All foods are okay for consumption when someone has CD. It's recommended to choose foods from all food groups in pursuit of obtaining a healthy nutritional intake. When experiencing a Crohn's flare, it's advised to try to avoid fresh foods (veggies, fruits, grains) that have a lot of insoluble fiber. An example is an apple. It's best to take the skin off and only eat the flesh of the apple. It is much easier to digest and one will avoid harsh fiber that's harder to digest during a flare. This type of restriction is only temporary - just recommended while in a crohn's flare. Nuts, seeds, harsh skins of fruits and veggies are all examples to try to eliminate while in a flare.
Each patient is different, however, and everyone has individual intolerances to certain foods while experiencing crohn's. It's important to monitor foods that may cause GI upset, even when one isn't experiencing a flare. Those are the foods that you have to avoid, while the next crohn's patient can consume them with no problem. Again - a lot of it is individual intolerance.
CCFA has a wonderful brochure on nutrition and diet. It's called "Diet, Nutrition, and Inflammatory Bowel Disease". You can get a copy of the brochure by contacting CCFA at firstname.lastname@example.org.
Q. Where can I find information about what to eat, how to prepare etc?
A. CCFA has a wonderful brochure on nutrition and diet. It's called "Diet, Nutrition, and Inflammatory Bowel Disease". You can get a copy of the brochure by contacting CCFA at email@example.com. Or you can download a copy at:
Q. My 17 yr old daughter with UC is currently on Delzicol and Prednisone due to a recent flare...she is just starting to wean from the steroid and is currently at 30mg/day. She would like to dye her hair. Is it ok to use hair dye while on steroids
A. I am not aware of any data to say that dying hair while on steroids, or any medication for that matter, is contraindicated. I have had several patients dye their hair on steroids, but other medications, and have not heard of any problem.
Q. I had surgery to remove my colon in 2000. Should I be supplementing my diet with vitamins? if so, which ones?
A. The food we ingest passes from the stomach into the small intestine (duodenum, jejunum, and ileum) before entering the large intestine (colon and rectum). The small intestine is responsible for absorbing most minerals and vitamins from the food we eat, and this process transfers these important substances from the bowel lumen to the bowel wall where the minerals and vitamins enter a network of blood vessels draining into the liver.
The principal role of the large intestine is to remove water and electrolytes from liquid waste to hydrate the body and produce solid waste. The large intestine also absorbs vitamins that are created by the colonic bacteria, such as vitamin K, vitamin B1 (thiamine), vitamin B2 (riboflavin), and vitamin B12 (cobalamin). However, the bulk of these vitamins are absorbed in the small intestine through normal processes.
Q. My 16 year old son was recently diagnosed with Crohn's disease. He was also diagnosed with Eosinophilic Esophagitis. He has had multiple life threatening food allergies and asthma since birth. Is there any relationship between food allergies and Crohn's disease? Could an offending foods cause inflammation and Crohn's like symptoms in the GI tract?
A. There have been several studies evaluating if a specific diet causes Crohn’s disease and there has not been a clear link found so far. Crohn’s disease is not considered an allergic disease. Celiac disease is caused by gluten (found in wheat and barley) may cause symptoms that are similar to Crohn’s.
Q. My nine year old granddaughter has Crohn’s disease. She is doing well and feels fine. Since she is doing well, is there a need for her to attend various CCFA programs and events?
A. It is wonderful to hear your granddaughter is doing well. She would be a wonderful role model for other patients that are not in remission. The purpose of CCFA events is various, including education, networking and fundraising. Many of the events are meant to educate patients and caregivers about Crohn’s disease and ulcerative colitis and how it is cared for by medical providers. Some of the events are social, to provide social support and networking. Your granddaughter and caregivers can select which events is the right fit.
Q. I am 59 and was diagnosed with Crohn's in April of 2013 after an intestinal blockage in the ilium. I am currently on 100mg of azathioprine. Is there anything I can do to unclog the intestine as soon as the symptoms start? I'm not currently on a special diet and only take a calcium supplement.
A. You may want to discuss diet with your doctor and possibly also a dietician. It may be helpful to avoid foods that are difficult to digest, particularly fresh fruit and vegetable skins – as well as excess fiber. These types of foods are more likely to get stuck in an intestinal narrowing and cause a blockage. If you feel like you are having early symptoms of a blockage, it may help to take only liquids, while you are waiting on further advice from your doctor. Depending on the situation and the level of Crohn’s inflammation, adding another medication when symptoms of obstruction start may be helpful. This is just another reason to let you doctor know when you are beginning to have symptoms that feel like a bowel obstruction.
Good information is available at CCFA.org
Q. My son will turn 26 in April and will no longer be covered by my insurance plan. He has been offered insurance through his employer, but we are trying to decide if he should continue my good insurance (under COBRA) with a $600 a month premium. He is currently using Humira to tar this disease. Is there anyone who can counsel us on making the best and most cost-effective choice?
A. Since your son is turning 26, it will be important to confirm in writing that he can be covered on you plan after he turns 26. You will need to compare coverage between the current and the proposed new plan. Compare things like in network doctors, hospitals, and covered medication. Not all insurers cover the same medications. Make sure that the new plan covers Humira and other biologic therapies. To discuss insurance options contact Patient Advocate Foundation at http://www.patientadvocate.org/index.php. Also check out www.healthcare.gov to sign up for insurance by March 31st.
Q. I was diagnosed with Crohn's in 2003. My bowel movements for the past five years were often urgent and uncontrollable. Now I am often constipated with severe cramps. I need to "grunt" in order to have a bowel movement most of the time. I'm currently not on any medications. Does this mean I could finally be hitting remission or are there complications associated with these symptoms?
A. Crohn’s disease can have a variety of behaviors making it challenging to determine if symptoms are the result of Crohn’s or an alternative explanation. Indeed, IBD providers often will require additional tests to confidently determine the cause. In the case of new constipation with severe cramping in an individual that was managing urgent diarrhea, there are several possibilities. First, a portion of bowel affected by Crohn’s may have developed significant scarring, called a stricture, which can lead to an intestinal blockage making it difficult to pass stool or even gas. Second, excessive use of anti-diarrheal medications (like Imodium) for symptom control may cause constipation. Finally, patients can develop constipation-predominant irritable bowel syndrome (IBS) which can cause these symptoms. You should notify your physician of these symptoms; an imaging test and other diagnostics may be ordered. As an additional note, in the majority of patients long-term maintenance treatment is recommended to suppress Crohn’s disease activity; the disease can often be quite active without causing symptoms.
Q. It was recommended that I try the FODMAP diet to help decrease symptoms of bloating, gas, and cramps. What is known about this diet?
A. FODMAP is a diet researchers from Australia have studied to help IBS symptoms. FODMAP is defined as: Fermentable Oligo-, Di- and Mono-saccharides, and Polyols. The FODMAP diet approach was initially focused on patients who experience irritable volume of liquid and gas in both the small and large intestine. The more common types of carbohydrate studied in the FODMAP research are fructose and lactose. Some other carbohydrates are considered sugar alcohols such as orbital and mannitol. These sugar alcohols are found in many sugar free and diabetic foods. There are also some non-digestible fibers called fructans and galactans that are found naturally in whole foods such as fruit, dairy, beans and grains. At this time, FODMAP diet is considered a theory. The theory is that FODMAPs can cause IBS symptoms or chronic digestive complaints such as pain, distention, gas, bloating excessive burping, diarrhea and constipation. The belief is that FODMAPs can produce an increased volume of liquid and gas in both the small and large intestine. The list of FODMAP foods is quite lengthy. It's important to discuss the list with your GI Physician and a Registered Dietitian. The thought to eliminate all or most of the foods from the FODMAP list if you're struggling with IBD symptoms may be tempting. But, restricting such a lengthy list could result in an imbalance in consuming a healthy diet. It's also important to consume a relatively high fiber diet when you are experiencing an IBD remission. So, one must try to remember the FODMAP diet is still in the research phase.
Q. I was diagnosed with UC 5 years ago and after a year of trying out different meds my dr. found a combination that worked for me. I started off with 60 mg of prednisone and have since then tapered down to 5 mg. I have been on that dosage for the last few years. Is it safe for to be on steroids for so long?
A. While 5mg is a low dose of prednisone, there is no ‘lower limit’ for what is considered safe. So while it is better than being on 60mg/day, it can still be associated with risk of side effects at a lower frequency. If there are medical alternatives available, then continued attempts should be made to come off even the 5mg/day of steroids, particularly in younger individuals where several decades more of exposure may be expected. In contrast, if someone is older or has significant co-morbidity that precludes further medical treatment, then it is reasonable to stay on long-term low dose steroids recognizing that the risk of side effects remain significant in that situation. Consideration should also be given for potential surgical treatment as surgery for ulcerative colitis is curative and would help coming off the steroids.
Q. I have Crohn’s and have anemia and I get monthly shots of B12. I have trouble breathing with stair climbing or bending over and sometimes just a brief walk to another room. I rest as much as I can. How can I gain my energy back?
A. There is increasing recognition of fatigue and low energy as an ‘extraintestinal’ manifestation in patients with Crohn’s disease. Sometimes there is a nutritional cause for this such as low B12 or low iron and anemia. If you are still anemic and are deficient in iron, that could be a cause for your symptoms. Sometimes a gradual exercise program is able to help with improving exercise tolerance and reduce fatigue. Of course, it is important to ensure that your Crohn’s is under remission and that there isn’t an alternate explanation for your trouble breathing including problems with the heart or lungs.
Q. I am 21 years old and seriously considering having my colon removed. I've been in and out of the emergency room since December of 2012 because of flare ups and most recently c-diff. I feel colon removal would be my best bet. I'm wondering how it affects the intimate part of my relationship with my boyfriend. Is it something you can remove during intercourse? Something that gets in the way? I'm a little unsure of the entire process.
A. You should have your surgery done by an experienced colorectal surgeon who does these procedures on a regular basis. In patients with severe disease, patients report an improvement in quality of life including sex life after surgery because they are healthier and off medications. That being said the surgery may impact your fertility (ability to get pregnant on your own) though the new laparoscopic approaches have less impact on that. In successful surgeries, dyspareunia (pain with intercourse) or other alterations of sexual function are not expected so your intimate part of your relationship should not change. There is an increased risk of fecal incontinence but not more than you have now with uncontrolled disease. Your surgeon should review the sexual side effects with you in detail prior to surgery.
Q. I work in a highly stressful call center environment. I am constantly in the bathroom at work and have only limited bathroom breaks. I'm not sure how much more I can take. I'm worried about losing my job. Any recommendations
A. If going to work is not possible, one should discuss with their doctors about getting a medical leave or temporary disability. The Human Resources staff should be able to provide the needed paperwork.
Q. Is there any new research on diet and IBD?
A. In the study “Dietary Patterns and Self-Reported Associations of Diet with Symptoms of Inflammatory Bowel Disease”, completed by Cohen et al. (2012) as part of our CCFA Partners research initiative, yogurt, rice, and bananas were more frequently reported to improve symptoms whereas non-leafy vegetables, spicy foods, fruit, nuts, leafy vegetables, fried foods, milk, red meat, soda, popcorn, dairy, alcohol, high-fiber foods, corn, fatty foods, seeds, coffee, and beans were more frequently reported to worsen symptoms. You can find out more information about these results in the abstract or manuscript of this study published here: https://cgibd.med.unc.edu/ccfapartners/results.php .
Q. I have been a UC patient since 1997 and due to the UC, am anemic as well, but have now been diagnosed with breast cancer too. Will chemo or radiation adversely affect the UC? Should I continue with Remicade?
A. a. You absolutely need to discuss this with your gastroenterologist and oncologist. They need to agree on what therapies you can and cannot continue with breast cancer. Some patients continue remicade after treatment for their cancer, particularly if they are considered cured. However, doing remicade while doing chemotherapy with active cancer is more tricky.
b. The chemotherapy may potentially aggravate your colitis. As the radiation is to your chest, that should not impact your bowels, but radiation to the abdomen can definitely impact colitis
c. I would suggest you have your oncologist contact your GI to discuss this further and come up with a safe treatment plan.
Q. Can people with Crohn’s safely donate blood. I'm 16 and in my state old enough to donate, however my parents are concerned just because of my Crohn’s I shouldn't donate . My mom also said because I take 6mp they won't let me donate? I'm not having a flare and meet all the criteria. Is there any reason that I can't donate if my blood counts are currently fine?
A. Crohn’s disease will not disqualify you from donating blood. On the other hand, Crohn’s that is not well controlled and having complications related to Crohn’s disease such as anemia are reasons you may not be able to donate. Treatment with 6-mercaptopurine will not disqualify you. More information is available at the American Red Cross website, www.redcrossblood.org.
Q. My son is an athletic 16 year old diagnosed this year with CD. He pushes himself very hard physically but is unable to build muscle despite eating mostly protein, fruit and vegetables. He is extremely fatigued. He is on Pentasa, Flagyl and Methotrexate (oral) - 3 weeks. Will he stop feeling so tired? Will he ever get back to normal again? Can he continue to pursue athletics now that he has Crohn’s or is that hurting his progress toward remission?
A. The symptom of fatigue may be a combination of factors related to Crohn’s disease: active disease which will cause fatigue and even weight loss, anemia from blood loss related to the disease, and malnutrition due to inability to absorb nutrients adequately. So all these factors need to be taken into consideration and addressed to help him improve. Methotrexate’s clinical effect may take up to 12 weeks so it is too early to know if he is a responder to medical therapy. If his Crohn’s is very active, he may have physical limitations and he may be placing himself at risk for complications and increased symptoms with moderate-high intensity exercise. Once he is in remission or has mild symptoms he may resume his regular activity with guidance of his physician. In fact, exercise is encouraged to maintain muscle mass and encourage well being when inflammatory bowel disease is not very active.
Q. Do people ever gain weight after colonectomy surgery?
A. Patients’ weights can respond differently to having their colons removed. For example, patients who have taken steroids for an extended period of time often experience weight loss after their colon surgery because they are able to successfully discontinue their steroid therapy. Similarly, patients kept inactive secondary to their disease may lose weight after the affected bowel is removed because they can resume more vigorous activities after recovering from surgery. On the other hand, patients whose diet or caloric intake was limited by their disease, will often gain weight after their colectomy because they can return to a more healthy diet that enables their bodies to rebuild.
Q. Is there a place for fast or “junk” food for kids with IBD?
A. Children with IBD face special challenges, and eating nutritiously is high up on the list. Parents would like to think that there’s no place in a healthy diet for fast food, but this may not be true. Some of these foods provide a valuable supply of nutrients as well as calories. Take pizza, for instance. The cheese offers calcium, protein, and vitamin D; the tomato sauce provides vitamins A and C; and the crust supplies B vitamins. The same is true for other popular favorites such as hamburgers or cheeseburgers, although all of these foods also contain more fat and salt than should be consumed on a regular basis. Milk shakes and ice cream also offer a good source of calcium, proteins, and calories. If lactose intolerance is a problem, that can be overcome by taking commercially available lactase in tablet form before consuming any dairy products.
Q. I'm diabetic and I also have UC. Many people say that white foods like pasta and rice are good for their UC. But all these carbohydrates are not good for my diabetes. Do you have any diet suggestions?
A. White foods such as white pasta or white rice are considered refined foods. In other words, the grain has been processed to a degree where virtually all nutrients and fiber has been eliminated. The manufacturers fortify (or add back in) the food with vitamins and minerals, yet most time the refined food in still void of plentiful fiber as compared to the grain in it's less refined form.
Yet, it's best to consume foods with a higher fiber content. Not only for nutritive reasons and colon health, but fiber also contributes to foods metabolizing slower than it's refined counterparts. Fiber helps food digest at a slower rate and helps maintain blood sugar at a more even keel.
You may choose most foods with a higher fiber content (non-white pastas and grains) when your UC is in remission. It's been suggested to limit a high fiber diet when you're experiencing a UC flare. With some, the high fiber foods can irritate the intestinal lining where the UC ulcers are present. During this time, also become more aware of your blood sugar regulation. If you find your blood sugar seems to fluctuate more with white refined foods, then you may have to experiment with combining some white and some higher fiber grains to help maintain your blood sugar. You also may not be troubled with higher fiber foods during a flare and substituting white refined foods during this time may not be necessary. It's a little trial and error for some. Introducing white refined foods may be temporary and may only last the time period of the UC flare. Become more aware of your blood sugar regulation, bathroom regularity, fluid intake, along with all other UC flare symptoms.
Q. I was recently diagnosed with UC in October of 2011. I have been on and off prednisone and we still haven't found a happy medium to all the medicines. I am off of the prednisone now and have been for a few months, but my weight is continuing to fluctuate. I am a 20 year old female and I eat relatively healthy and stay away from the foods that upset my UC. How do I control this weight problem?
A. Many people will recognize weight gain as a common side effect of prednisone. Many will also recognize weight loss as a side effect of significant inflammation from IBD due to protein loss from severe inflammation or avoidance of foods that worsen IBD symptoms (pain, diarrhea). Fluctuation in weight becomes a more challenging problem to pinpoint as it is common in society and many people without IBD have problems with fluctuating weight. So the question is whether this is a slow to resolve residual effect of the body trying to gain equilibrium after predictable cycles of inflammation (weight loss) and prednisone (weight gain) for over a year, an unrelated medical problems, such a thyroid problem, or a problem unrelated to IBD that is common in society, which is weight fluctuations, commonly brought on by stress, altered sleep cycles, and cycles of dieting and return to comfortable eating habits. Although most likely the solution to this problem is time with the good eating habits reported above finally "winning" as the body equilibrates after a year of inflammation and prednisone, it is important to speak with your doctor to exclude medical issues such as thyroid problems and to review your diet and lifestyle choices that affect weight.
Q. I have been going through some rough flares recently and am so tired all the time. I used to go to work with initiative to accomplish goals and be successful in what I do. Now I just do not care. I know that I am blessed to have a job, but struggling with this disease has taken away my drive for work, exercising, and even spending time with my family. Do you have any advice on how to get the drive back?
A. Fatigue is a very common problem in patients with IBD, both during disease flares but also during times of remission. This fatigue can come with poor sleep, low energy, and depression, if symptoms become severe enough. Sleep disturbance is common in patients with IBD, and there are several potential reasons for this, one of which is that the inflammatory substances in the gut may also have an impact on the brain. Medications used to treat IBD affect sleep, especially steroids. If poor sleep is contributing to the symptoms you describe, there are things you can try to get better sleep. These techniques, sometimes called ‘sleep hygiene,’ include setting a specific schedule and being very consistent in sleep and wake times. People who sleep the best often engage in relaxing activities before bedtime, rather than watching violent TV or movies that can arouse people. It is important to get all of your sleep at one time, and you should avoid napping during the day, especially if you find yourself tossing and turning at night. People are encouraged to avoid alcohol, as this can worsen the quality of sleep and make it less refreshing.
When “drive” is low, a jump start is often needed, and the longer you remain ‘stuck in a rut,’ the harder it can be to break out. However, just like bad habits can breed more bad habits, good habits can lead to more good habits and help you to break out of your low motivated ‘funk’. Scheduling your day (and sticking to it!) can be very useful with this, and I would encourage you to detail your activities for the week. Be very specific and build enjoyable things into your schedule (exercise, time with family), as well as things that you have to do (work). The longer you can stick to this routine, the easier things become. Sometimes, low motivation and poor sleep may be signs of depression or other mental illness, so if your symptoms are going on for more than two weeks, it is worth discussing with your physician as you may require more help
Q. My wife just up and left me 4 weeks ago and my stress level is at an all time high. I feel like I'm having a breakdown and my stomach has been in constant turmoil. I tried now for 4 weeks to tough it out and let myself heal emotionally the natural way, but it just isn't working. Any advice would be greatly appreciated on how to deal with the stress and managing my Crohn’s disease.
A. Life stress, especially the loss of a relationship, has been linked with worsening gastrointestinal symptoms in patients with IBD. This is thought to be due to the strong connection between the gut and brain, especially the areas of the brain that regulate our emotions. Though I’m sorry to hear about your recent break-up, there are several things you can do to decrease stress and help yourself feel better during this challenging time. First, it is very important to get back to activities that are enjoyable for you, even if it is difficult to force yourself to do them. When we relax or find pleasant diversions, it gives our brains a rest from processing the stress. Taking 10 minutes a day to focus on relaxation can be effective in decreasing stress. One breathing exercise involves deep slow breathing…counting to 4 while breathing in through your mouth, holding it for 4 counts, and letting the breath out through your mouth over 8 counts for 10 breath cycles can decrease stress. Second, finding the company of trusted friends is especially important when dealing with stress, as positive social interactions have been shown to decrease the stress response that affects the gut. Finally, if stress is chronic or extreme, it can through a switch in the brain causing an emotional reaction to become a more clinically significant depression or anxiety disorder which can benefit from the services of a professional therapist or counselor. Letting your gastroenterologist know about your life stress is a good place to begin.
Q. I was diagnosed with IBD 10 years ago and take Azathioprine. I am very active (cardio & weights 5-6 days a week); however I always feel like my muscles are sore. I drink almost a gallon of water a day, and eat a good amount of protein. My doctors can't give me answers, and the lab work didn't give any info. Any suggestions for diet? It this common for people with UC or CD?
A. We recommend a good, well balanced diet without supplements in general. Check out some additional information on diet and IBD from CCFA’s resource: http://www.ccfa.org/resources/diet-and-ibd.html
Q. I was recently diagnosed with Crohn's although I've probably had it for years and didn't know it. Being told you have what is a lifelong disease that will never be cured, and will likely only get worse and may lead to surgical removal of parts of your intestines is really like being continually smacked in the face. How exactly do you accept that, I mean truly accept it? Where do I start?
A. The first place to start is to give yourself permission to have a reaction and to know that it is normal to have a range of responses when diagnosed with Crohn’s disease, something unexpected and life-altering. It is natural to go through some type of grieving process about the loss of health, similar to how people react to the loss of a loved one. The responses involved vary among individuals. Some people get sad, others get angry but there is no right or wrong way to grieve. What is important is that you recognize your feelings and remind yourself about other difficult challenges you have adjusted to in the past. Although the passage of time is the best healer, there are active steps that have helped others with Crohn’s disease accept their diagnosis. Talking about it with others is a good first step whether it is good friends or family or through a CCFA support group or activity. Some patients find it helpful to journal about their experiences as a way to work through the emotions. Others find it useful to focus on other aspects of their lives that they can control. For example, thinking about three positive things in your life or three small tasks or steps you will achieve that day. Finally, others have found that “finding the silver lining” about a situation (i.e., something positive or something that could be even worse by comparison) helps them feel better. In fact, many studies show that optimistic thinking can positively influence how well your body copes with the disease and how well your immune system responds to the medications or your gastrointestinal tract heals from surgery.
Q. I play tennis 3 times per week. Will I be able to keep playing the same as I used to now that I have Crohn's disease?
A. When the Crohn’s disease is in remission you should be able to play tennis as before. It is best to listen to your body. During times of increased disease activity you may have increased fatigue and be unable to do everything that you had done previously.
Q. I have Crohn's and am almost always extremely dehydrated - eyes so dry I can't blink, finger tips puckery, mouth dry no matter how much water I drink. Is this from Crohn's? What should I do?
A. Dehydration can be caused by a number of disorders and can also be associated with electrolyte imbalances. We lose water through many routes including moisture in our breath as well as water in our stool, sweat, and urine. It is important to maintain an appropriate intake of fluids such that you urinate at least 4-6 times each day. You can also look at the color of your urine. If your urine is a light yellow to clear, this can indicate you are adequately hydrated. Some patients with Crohn’s disease suffer from watery diarrhea that diminishes their water and electrolytes. These persons should work with their physicians to manage the diarrhea, but they should also replenish their losses by drinking sports drinks that contain both water and vital electrolytes such as sodium and potassium.
Q. Should I get a flu shot when on a biologic?
A. It is recommended that patients on immune suppressants and/or biologic therapy receive a flu shot annually. However, patients should not receive the live virus vaccine (nasal spray vaccine).
In addition, you should not receive the flu vaccine if any of the following apply to you:
a. Severe allergic reaction to eggs
b. Severe allergic reaction to the flu vaccine
c. History of Guillain-Barre syndrome
d. Sick with fever at the time of vaccination
Q. I am currently having a flare of Crohn’s colitis with swollen and very painful joints as well as erythema nodosum. I am starting prednisone, methotrexate and ciprofloxacin to go along with asacol sulfasalazine. Can you explain how these will help? Also, my job demands that I’m on my feet for 12 hour shifts. How much work should I miss if any at all?
A. Having symptoms of Crohn’s disease outside the gut itself is a very common scenario for many patients. For many, joint disease and swollen joints can be more debilitating than the colitis symptoms itself. Furthermore, erythema nodosum (red lesions often occurring on the shins) are very painful. It sounds like your doctor is trying to combine a variety of medications to treat the Crohn’s disease, including immunosuppressives (prednisone), immunomodulators (methotrexate) that will hopefully be able to get you off the prednisone quickly and prevent you from having to go back on them, antibiotics (ciprofloxacin) to decrease bacteria which may be inciting some of the Crohn’s disease, as well as mesalamines to reduce superficial inflammation. However, the mesalamines have not been shown to be robustly effective in Crohn’s disease. Sulfasalazine has some anti-arthritic effects, which may work through the sulfapyridine antibiotic component of the medication.
You and your doctor should have a frank conversation about what the timeline to recovery might be, and how this will impact your ability to go to work.
Q. What are your thoughts on trying a gluten-free diet for IBD patients?
A. Trying a gluten free diet is an option for IBD patients, but what the research community knows at this juncture is that there are no special diets for IBD. The patient’s diet may affect the symptoms of IBD, but not the inflammation. A gluten-free diet excludes grains that contain the protein gluten. Gluten-free is used primarily in patients with celiac disease. Yet, there is talk amongst the IBD patient community that anecdotally some have had some positive results from avoiding gluten in their diet. One can try avoiding gluten-based foods for a couple of weeks—start using a food journal and document any possible physical positive or negative results from the change in diet. If the positives outweigh the negatives, then perhaps a gluten-free diet may be a step in the right direction towards a flare free life for some. But studying gluten-free or any other diet regimen in relation to IBD has been limited due to most studies are small, resulting in anecdotal outcomes. Diet may have an impact on the disease, but research has been inadequate to show how the different mechanisms proposed affect the gut bacteria and the immune system.
Q. Are there any foods that help reduce gas or mal-odor?
A. It’s important to remember there are vegetables that can produce more gas than others. Cruciferous vegetables (i.e. broccoli, Brussels sprouts) are examples of the type of vegetables that can produce more gas than others. This can potentially affect how a patient feels, perhaps contributing to the patient’s IBD symptoms. These vegetables, however, will not cause harm to the GI tract. Yet to answer your question, I’m not aware of foods that reduce gas or mal-order.
Q. Does drinking alcohol have an effect on symptoms and flares? I'm finding that sometimes I'm okay, but then sometimes it can trigger a bad flare. Do most people with IBD simply quit drinking altogether?
A. For many, IBD symptoms don’t seem to worsen with occasional drinking; however, some individuals find that there are detrimental effects with even a small intake of alcohol. Usually, one has to find out how their body tolerates alcohol through trial and error. It seems the irritation that may occur in the upper GI tract doesn’t appear to affect the lower GI tract.
Q. My 7 year old was just diagnosed a few weeks ago with Crohn's and we are struggling with finding food he will eat. He's so upset that he can't eat the things he loves. Do you have any recipe ideas for children?
A. Usually when folks are in a flare, it’s best to follow a few simple diet rules to help the patient feel better and perhaps decrease the severity of some of the IBD symptoms. These guidelines don’t necessarily help everyone because individuals tolerate diet choices differently. Not all IBD patients are affected by the same food. Usually, high fiber foods, high fat foods, caffeine, alcohol, carbonated beverages, dairy, sugar alcohols, and spicy foods are the target foods that can potentially trigger IBD symptoms if a patient is having a flare. But, if a patient is flare free, and not having any IBD symptoms, then the diet and the ‘favorite foods’ can be brought back in to the normal routine. At this point, I don’t have specific recipe for IBD kids. However, I recommend eating favorite foods if the patient can tolerate them. If there is a tolerance issue, perhaps a modification of the favorite food can be given to the child (i.e. Popcorn can be intolerable for some individuals. Purchasing hulless popcorn could help the patient feel like he/she is still able to eat popcorn, but not suffer any GI disturbance.)
Q. I have horrible odor in my bowel movements and my flatulence all the time, 24/7. What can I do? I take adalimumab and eat a regular diet. I had my colon removed and ever since then I have had this problem.
A. It sounds like you had ulcerative colitis and underwent a total proctocolectomy – ileal pouch anal anastomosis and are on adalimumab for inflammation in the pouch. If this is the case, then you will be having bowel movements through your anus, as opposed to an ostomy bag. Your small bowel is being asked to perform the function of the colon, and serve as a reservoir for the stool until you evacuate. To that end you would also have the high volume of bacteria in the pouch just as if you had a colon. This necessarily results in Small Intestinal Bacterial Overgrowth (SIBO) in which the bacteria proliferate to a much greater degree than they would in the colon -- as there is more digestible food to be metabolized. The gaseous byproducts lead to bloating, gas and flatulence.
The treatment of SIBO is varied and controversial. Many physicians will start with a trial of probiotics. You may need a course of antibiotics both for the SIBO as well as for the pouchitis that you may be taking the adalimumab for. Be sure to discuss treatment options with your healthcare team.
Q. I'm a young adult that has been living with UC for 15 years. School is starting soon-and I'll be running 14+ hour days during the week. Do you have suggestions for food plans/diets? I've been trying to do a low-residue diet.
A. Stick with the diet that works for you. If you generally do a low residue diet then that should probably be continued. Eat has healthy as possible and don’t forget time for rest. Life does not necessarily become less busy when you are done with school. Don’t forget to take a multivitamin, calcium and vitamin D. Take a look at some of the diet tips at CCFA.org.
Q. Do you have any weight loss recommendations for IBD patients, particularly teenage girls?
A. There are no specific weight loss regimens that are recommended for patients with IBD regardless of age or sex; certainly it’s important to make sure that any diet is well-balanced so that adequate nutrition is maintained. Weight loss should be done slowly and very extreme dieting and exercise regimens should be avoided. An assessment of body mass index would be a good first step and consultation with a nutritionist is advised.
Q. I have been taking budesonide for more than 2 months for lymphacytic colitis. I asked my doctor about supplementing with L-glutamine which he ok'd. I did not ask him about supplementing with L-Arginine. Would it be alright to use arginine as a nutritional supplement?
A. Yes, L Arginine would be safe to take. There is a lot of interest in determining if certain amino acids, proteins, and other supplements are effective at controlling inflammation. Generally, the amino acids listed are safe and I do not have concerns with these. There are other protein substances that if taken at exceedingly high doses without enough water intake that can present a problem. Those listed by the person asking this question should not present a problem.
Q. Do high-fat foods worsen IBD symptoms?
A. Yes, high fat foods, caffeine, alcohol, and refined sugars may all increase IBD symptoms, i.e. gas, diarrhea, bloating, cramps. It is not clear if high fat foods actually worsen the IBD itself. Meaning, we don’t yet know if high fat foods will lead to more inflammation. However, there are enough other medicine studies showing the detrimental effects of a high fat diet, and an increase in inflammation, in the heart and blood vessels, that avoiding high fatty foods is healthier anyway.
Q. At age 14, I was diagnosed with UC and had a colectomy and j-pouch surgery. About 4 years ago (and after 11 years of wondering why I was still sick) I was re-diagnosed with Crohn's, but I'm already without a colon. I have found dietary information on Crohn's, but not for someone without a colon as well. I am still having trouble figuring out what to eat that won't cause problems, any suggestions?
A. There is no diet that has been clearly proven to have a benefit in patients with Crohn’s disease though the internet is full of anecdotes (e.g. specific carbohydrate diet, paleolithic diet, gluten free, etc). In general, we know diets high in animal fat and animal protein increase the risk of IBD; nitrites, found in processed foods, luncheon meats, can increase risk of flares; curcumin (turmeric) may be helpful. I recommend a Mediterranean type diet to my patients as it is a heart healthy and anti-inflammatory diet high in linoleic acids and omega-3’s.
Specifically for pouch patients, it depends on whether you have any strictures – in this setting you would not want high fiber. If there are no strictures, then you would want to add fiber supplementation to thicken up the stool.
Q. Is there a risk in having plastic surgery if you have been on immune suppressants or biologics? I have not had infliximab in 4 months, I stopped taking azathioprine three months ago, and I also took steroids but have tapered off. Is it safe to have any surgery after all this medication?
A. The risk of anti-TNF therapies (such as infliximab, adalimumab and certolizumab), 6-mercaptopurine or its prodrug-azathioprine, and corticosteroids have been assessed for postoperative complications in several studies. The risk of postoperative complications with anti-TNF therapy is not clearly increased based on these studies. The same is true for 6-mercaptopurine/azathioprine. Whereas for corticosteroids, if at the time of surgery it is greater than 20mg a day it may increase risk for complications.
It takes at least 4 half-lives for minimal drug concentrations to remain in the blood stream. Based on a half-life of 7-9 days with infliximab, infliximab exposure 4 months ago should not affect surgery. The half life of azathioprine’s active metabolite (6TGN) is between 3-13 days, so stopping azathioprine 3 months ago should not have an effect. The half of prednisone is 3-4 hours.
Q. I've read that people with ulcerative colitis should be on a gluten free diet. Is this true?
A. Gluten is not a known stimulant of ulcerative colitis or Crohn’s disease. Some individuals have gluten intolerance, which causes gastrointestinal symptoms such as bloating and abdominal discomfort. So if a patient also has ulcerative colitis the gluten intolerance may add to symptoms already present.
Q. I have had Crohn’s disease for 48 years and have had a total colectomy and ileostomy and four stoma resections when fistulas appeared. My B12 always appeared normal. I recently read an article from American Family Physician on Vitamin B12 deficiency and purchased 6,000 IUD sublingual B-12 tablets and took them for the last two weeks daily. I feel great with strength and stamina, skin improving, and mentally alert. The article cited 1,000 daily supplementation—is this okay?
A. The Recommended Dietary Allowance for vitamin B12 for adults ranges from 2.4 to 2.8 mcg daily. The article suggests 1000mcg a day for patients with vitamin B12 deficiency. Since your vitamin B12 levels have been normal, you should speak with your doctor about the right dose for you. Although supplementation with excess vitamin B12 is relatively safe, there are toxicities such as blood clots that have been associated with too much vitamin B12.
Q. I completed my first half-marathon in December with Team Challenge and would really like to do another. What is recommended in terms of nutrition supplements during a long run for someone with Crohn's? It seems that even with the gels and chews available, I'm just not able to keep my energy up.
A. For long distance running with Crohn’s, the most important part is to be sure you are keeping up with your hydration, both before race day and on race day. Every individual’s needs are different and dependent on their fluid losses (which includes most importantly sweat and stools (diarrhea)). An average recommendation (for people without bowel disease) is to drink 3-6oz every 15-20 minutes during the run (about 1 cup of water every other mile). For a starting point, try to estimate your sweat rate (weigh before and after a good hour run and then convert this to ounces/hour of loss). You will need to be replacing those losses plus adding more for any diarrhea and more if it is hotter. In regards to carb intake (gels and chews), be sure you take something pre-race, and then at least 45 minutes into the run, to help prevent losing steam early on. You will have to adjust this to your own body and may need to take more of these then other people given your Crohn’s. Try out various formulations to see what works best for you. Make a hydration and nutrition plan for race day beforehand and talk it over with your doctor to further tailor it to the specifics of your disease.
Q. I am running my first half marathon in less than 2 weeks. I’ve been training since November, but I’m having lots of issues and some days it’s just impossible to run - not because of the pain, but because it’s just not in me to run that day. I know that most people are supposed to carb load before a race, but what should someone with Crohn’s do to prepare diet wise?
A. First things first, in regards to poor energy, be sure to talk with your doctor to ensure that your Crohn’s disease is adequately treated. Next, nutrition during training for long distance running is important both for people with and without Crohn’s disease. You should be eating a healthy, balanced diet in addition to being sure you are staying adequately hydrated. Carbs are important in all your meals to provide the energy stores you need for running and protein is especially important post-race to help repair your body. On race days, you can try to eat something light (like a banana or a bagel or something you know you digest well) before the run. It is also important with long runs to consume snacks during the run. There are a wide variety of energy supplements (carbs) that come as gels, chews, or bars that you can take during the run. You want to be sure to consume these early on in the run, and then periodically throughout (make sure you don’t wait too long and lose steam). Many recommend these every 30-45 minutes during the run. You will have to try various products and see what works best for you. And again, being sure you are adequately hydrated is a very important part of this as well.
Q. I was 19 when I was first diagnosed with Crohn’s. I have had 2 resections. As time went on I was diagnosed with IBS and now I also have diverticulitis. How do I deal with diet? Crohn’s is low fiber and IBS and Diverticulitis is high fiber.
A. There is a rather obvious link between diet and gastrointestinal illnesses. Unfortunately, it is not a very well understood link at this point in time. What’s certain is that the “wrong” diet will not result in any prolonged negative effects. That being the case, you should feel free to experiment with low or high fiber diets, with the assistance of an expert, until you find the one that’s right for you. No matter the choice, you won’t harm your Crohn’s, IBS, or diverticulosis.
Q. My son is 14 yrs old and had his colon removed a couple weeks ago. What can I feed him to put some meat on his bones? He's 5ft 6in and only weighs 105lbs. The doctors tell him he needs to really concentrate on keeping hydrated so he drinks lots of water and Gatorade, but those things fill him up so he isn't hungry.
A. A diet high in protein calories is the best thing for him at this time. It would likely be advisable for him to meet with a nutritionist to get a detailed description of how to accomplish this, but all calories are good calories and high protein calories are best.
Q. I have collagenous colities & celiac disease. Should I take a probiotic or any specific vitamins? I take 600 mg calcium pills 3 times a day and multi vitamin and chlorestramine drink 1 or 2 times a day as needed.
A. Probiotics have not been shown to be beneficial for collagenous colitis or celiac disease. Patients with untreated or poorly treated celiac disease can develop malaborption of vitamins and minerals like vitamin D and calcium. Therefore, screening for deficiency in vitamin D and repleting the vitamin D if the level is low is reasonable. Also, screening for bone loss related to celiac disease with a DEXA or bone density is indicated. If bone loss is present, calcium and vitamin D supplements should be given. If the celiac disease is under good control and the bone mineral density is normal, calcium and vitamin D would only be needed if you are not getting sufficient intake in the diet. A daily multivitamin is a reasonable thing for all patients to take. Cholestyramine is not a vitamin but is used as a treatment of the collagenous colitis.
Q. I have not had a flare up or problem for over 6 years now and haven't been on any medication for 14 months. Can I donate plasma?
A. Yes, you should be eligible to donate plasma.
Q. I have painful gas daily. Can I take simethicone or beano for this?
A. Beano (the enzyme that helps break down the sugar found in many types of beans) literally only works on breaking down arabinose, which is the sugar in beans. If you do not eat beans, then Beano will not help you. Simethicone breaks up gas bubbles that are in the stomach, but if the gas has already reached your intestine, then simethicone will not help either. Simethicone however is certainly safe to take.
Q. I feel like my Crohn's is always worse in the fall and winter, but it sounded crazy to think that the seasons impact the disease. Then I read that there is a link between vitamin D deficiency and Crohn's Disease. Is there any validity to this claim?
A. There is very good literature to suggest that some patients note a strong correlation to the season so your observation is not crazy. We think that the lack of vitamin D in Crohn’s patients can contribute to ongoing inflammation and that treatment with vitamin D supplements to restore normal levels can help disease symptoms.
Q. My son underwent a successful total colectomy 10 yrs ago for the treatment of colitis. He has become obese and unable to eat many of the typically recommended foods (high fiber veggies, raw fruit). What recommendations do you have for a low fiber diet geared to weight loss?
A. For anyone that needs to lose weight the recipe is always the same. Look at total calories in the diet and especially the intake of sugar and fat. I understand the difficulty with consuming raw vegetables and fruits; however, cooking the vegetables makes them more tolerable and just as beneficial in terms of nutrients and weight loss success. Prepare vegetable soups and purees and do not add a lot of fat. When trying to lose weight the amount of fruit in the diet should be limited to 2 per day. Try cooking the fruit, like baked apple as it becomes more digestible that way.
Your son can be successful with weight loss if he is cautious with the total calories he consumes and takes some time to be active. Keep vegetables and fruits cooked and eliminate sugar from the diet.
Q. Has there been any links shown between improved condition and a cessation of wheat in the diet?
A. There have been very few studies that have shown people with IBD do well on a wheat free diet. However, those people who have been tested for wheat sensitivity or intolerance and have a proven inability to digest it can benefit from this restriction. This situation is not common and most patients with IBD tolerate wheat products just fine. Be careful with eliminating excessive amounts of food from the diet. Remember that patients with IBD need a balance of nutrients and limiting wheat can cause significant reductions in total calories, which in turn can lead to caloric deprivation.
Truly evaluate the need for this kind of restriction before imposing it upon yourself. Going to a reputable allergy or immunology center would be recommended before major dietary changes like this are taken on.
Q. I have had ulcerative colitis for 31 years and had my large intestine removed 3 years ago. I am severely lactose and dairy intolerant and my Vitamin D count is very low. My doctor gave me a script for Vitamin D but it made me so sick I stopped it. Can it be because I have no large intestine to absorb this vitamin? What do you suggest? I can only eat certain foods, no veggies or fruits.
A. Vitamin D3 is a critical micronutrient that assists in the absorption of calcium and allows for many other bodily functions that are imperative for maintaining health. Recently vitamin D3 has been implicated in reducing the risk of certain cancers and reducing inflammation in the body. Remaining deficient in this nutrient is not beneficial and can lead to other disease states.
It is very important that you bring your body back to balance and make sure all vitamins are at recommended levels. As for getting enough vitamin D3 I recommend the following: 1) Consume more oily fish like salmon and tuna; 2) Try drinking more fortified orange juice and almond or soy milk (these also have a lot of calcium); 3) Have more eggs as the egg yolks have a good amount of this micronutrient; 4) Spend 15 minutes in the sun each day; 5) Try taking 1000 IU of vitamin D3 chewable on a daily basis, sometimes the prescription dose is 10,000 IU once a week and this can make you feel sick.
Q. I have colitis and just found out this year. I also compete in cycling and typically train and race 10-12 hrs a week. Is there any effect of this on the colitis? Could the physical stress cause a flare? Are there any recommendations for athletes with colitis for diet and training?
A. There is no evidence to suggest that exercise worsens inflammatory bowel disease. Exercise is important for bone health and for mental health. There are professional athletes with IBD. Some IBD patients have decreased exercise tolerance, but the available studies suggest this is mainly related to complications of IBD, such as anemia and poor bone health. There are also practical issues to consider. Patients with ostomies should refrain from contact sports, patients with active disease—particularly of the rectum—may need to be close to a bathroom, and some may need to be prepared for the occasional accident. The message, however, is that exercise should be done to the extent it is tolerated, it should be encouraged, and it is more beneficial than harmful in the majority of patients.
With respect to diet, a healthy one is the rule. For patients who have trouble keeping weight on, they should understand that physical activity burns calories, and so they will need more calories. The more strenuous the exercise the more (healthy) calories they will need. For most patients, especially those with inactive disease, the dietary recommendations for athletes with IBD are usually the same as athletes who don’t have IBD.
Q. I am about to start training for the CCFA half marathon. I have severe CD with an ileostomy. My ostomy is very active and there is a short duration where there is no output. I already have a problem low sodium and low potassium. I often end up in urgent care needing 3-4 liters lactated ringers. How will I avoid exacerbating these problems while training and during a day of half marathon?
A. Patients with ileostomies can have significant water losses, and importantly, sodium and potassium losses. For an athlete with an ostomy, the water, sodium and potassium losses from perspiration and increase respirations may also be substantial. Ostomy, perspiration (sweat), and respiratory losses must be accounted for when considering fluid and electrolyte replacements. If a patient is having difficulty maintaining hydration at rest, this should be addressed with their physician prior to introducing an intensive training program.
It is important to realize that most sports drinks do not meet the fluid and electrolyte needs of an athlete with an ostomy. Sports drinks may have too much sugar and, more importantly, not enough sodium and potassium. A patient with an ostomy may need pediatric hydration solutions (which are much higher in sodium and potassium) to maintain normal hydration.
Q. How effective are probiotics in reducing inflammation in Crohn's disease or ulcerative colitis?
A. Many studies have tested the effectiveness of probiotics in reducing inflammation in IBD. Results have been mixed for Crohn’s disease, with some studies showing a benefit, many showing no effect, and some showing that symptoms get worse. On the other hand, several recent studies have shown that probiotics may reduce inflammation in patients with Ulcerative Colitis. The choice of a specific probiotic should be discussed with your doctor, as they vary widely in make-up and stability in the GI tract.
Q. What is the role of sugar in the diet of an IBD patient? Which types of sugar are easier for the body to absorb?
A. Unfortunately, despite the extensive web-based recommendations on sugar and IBD, there is very little research on this matter. A recent compilation of various studies by Jason Hou, MD reported that high dietary intakes of total fats, polyunsaturated fatty acids, omega-6 fatty acids, and meat were associated with an increased risk of CD and UC. High fiber and fruit intakes were associated with decreased CD risk, and high vegetable intake was associated with decreased UC risk. Another researcher (El-Tawil) theorizes that factors, such as lack of zinc (common in patients with IBD, in particular Crohn's patients) may significantly affect the activity of some enzymes, such as disaccharidases and other digesting enzymes of carbohydrates, and that would lead to an increase of incompletely digested carbohydrates in the terminal ileum and continual stimulation of inflammation there. However, again the data is limited. Overall, a balanced healthy diet (I recommend a Mediterranean type diet for my patients) is the best option based on available data.
Q. Should you only make dietary changes during a flare—or is it also helpful to watch your diet at all times? For example is it wise to avoid high fiber foods all/most of the time? In other words can watching your diet help to prevent flares and/or the frequency of them?
A. Dietary recommendations must be individualized to reflect disease type, area of intestine involved, and the severity of the disease. While it is important to strive for a well-balanced and healthy diet all the time, sometimes flares of disease will cause more dramatic dietary changes to reduce symptoms. In your example, avoiding high-fiber foods is recommended in patients with IBD that have abdominal pain, cramping, or diarrhea after eating. However, some patients in remission and on maintenance therapy tolerate high-fiber foods without difficulty, and this is largely on a trial-and-error basis.
Watching your diet may help you to prevent symptomatic flares if you have Crohn’s disease associated with narrowing of the intestine, as intestinal cramps or pain in this setting may be more reflective of the intestinal narrowing more than the disease itself. Keeping a food diary is extremely helpful to assist identifying what foods and beverages you tolerate well, and what foods you should avoid based upon your symptoms.
The CCFA has a food diary template available for download at: http://www.ccfacommunity.org/ResourceCenter.aspx
Q. What is the best diet plan post a proctocolectomy or resection surgery?
A. There is no perfect diet plan for all individuals that have had an operation, but common recommendations for eating following proctocolectomy with reconstructive ileoanal pouch reconstruction include: 1) efforts to eat smaller, more frequent meals; 2) avoiding concentrated, sugar-dense liquids like soda, or greasy foods that can increase loose stools; 3) start slowly and increase intake gradually; 4) avoiding late-night meals – this helps to cut down on having to get up in the middle of the night to have a bowel movement; and 5) stay well-hydrated and drink plenty of fluids. Your surgeon and gastroenterologist will work with you to define goals for the consistency and frequency of your bowel movements. The consistency of your bowel movements can be modulated by the use of supplemental fiber, and the frequency can be influenced by anti-diarrheal medicines that slow the intestinal transit time. You will want to discuss with your doctors specific foods such as nuts, seeds, corn, and popcorn if they have given you problems or caused cramps in the past.
There is high value in maintaining a food and beverage diary in the first few months following surgery, as it will help you to identify foods that may give you more problems with bowel movements and foods that you can consume without difficulty. The CCFA has a food diary template available for download at: http://www.ccfacommunity.org/ResourceCenter.aspx
Q. I have had Crohn's since 1987 and am in my mid-40s. I currently take adalimumab twice a month and am doing very well on it. I had surgery in 2003 and they removed 65% of my large intestine and 35% of my small. My problem is that about 90% of the time I have a bowel movement (BM) after I eat. It can be embarrassing at times especially if my wife and I are out to eat with friends. Any suggestions on how to reduce this?
A. It is a natural reflex for the bowels to evacuate after eating a meal, to make room for the newly eaten food. However, when you have had surgery, such as you describe, that reflex may be exaggerated. One possibility that may help reduce the need to have a BM after meals, especially if you are planning to go out, would be to take an anti-diarrheal medicine, like Imodium, prior to the meal (be pre-emptive about it, don’t wait until it happens!)
Q. What type of dietary modifications can help in the symptoms of nausea and vomiting?
A. The first question to ask is why you are having nausea and vomiting. It is important to address the cause for these symptoms with your doctor so that, if possible, specific management can be aimed at alleviating the underlying reason for these symptoms (i.e. treating active disease or removing a blockage if it is present).
If these symptoms are related to an active flare, eating smaller more frequent meals will often help. Also, avoiding fiber, dairy, spicy foods, and high fat meals during flares can also help. If the symptoms are related more so to a chronic blockage (scar tissue) in the bowels, then eating a low residue diet (especially avoiding diets high in insoluble fiber) and again, eating small frequent meals, may help. Nausea and vomiting could also be related to medications used to treat IBD, so discuss this possibility with your doctor as well.
Q. Is exercising recommended in helping to manage the symptoms of IBD and do I have to take any precautions if I want to exercise?
A. Exercise is an important part of any healthy lifestyle and having IBD doesn’t change that. However, when you have active symptoms, you may not feel up to exercising. On the other hand, when you do feel well, regular exercise is encouraged. In general, the only limitations on exercise are what you impose on yourself. However, be sure to discuss your specific exercise plans with your doctor.
Q. Will maintaining a gluten-free diet help with the symptoms of IBD?
A. A lot of people claim that a gluten-free diet will help with symptoms of IBD. However, most people are not really intolerant of gluten, an entity that is found almost everywhere. In ulcerative colitis, the inflammation is in the colon not the small intestine so the effect of gluten has no direct effect. In Crohn’s disease, some feel that a gluten free diet helps them feel better. Most of this effect is from a healthier diet in general, since gluten free essentially means taking all the “crap” out of your diet and that you are eating healthier, eating foods made at home and not purchased pre-made or in restaurants.
Q. What type of diet or lifestyle modifications will help with increasing energy and dealing with the symptom of fatigue?
A. There are no diets that have been shown to definitively and consistently helped patients with energy. Carbohydrates give your body instant energy, but protein is important for longer term energy requirements. Making sure that a well balanced diet in terms of nutrients is important—if you are on a very limited diet then supplementation with vitamins like vitamin B12 and iron is necessary.
Q. I've recently introduced coffee back into my diet for about a week after being diagnosed with Crohn's. I have steadily been having more and more pain. Is coffee a known irritant?
A. There’s so much that’s not known about the influence of diet on Crohn’s disease activity and symptoms. Coffee is NOT known as an irritant, but if it makes symptoms worse, then you should consider stopping it. If, however, you would prefer not to abandon coffee, you can try re-starting it after stopping for a couple of weeks. This kind of re-challenge can be useful in distinguishing something that’s harmful to you from something that seemed to cause symptoms by coincidence.
Q. I am on immunosuppresents, so I am not looking for immune system boosters. However, are there any anti-inflammatory supplements which could help with UC? Fish oil, turmeric, etc?
A. Probiotics may help some patients with ulcerative colitis stay in remission. While fish oil and turmeric have also been studied, it is not clear that these will help most people. The best plan is to speak with your doctor about the supplement you would like to try, in the context of the medications you are already taking.
Q. I have experienced severe weight loss recently. My appetite is very low and I find it difficult to eat anything. What can I do to increase my appetite and start gaining weight or combat the effects it's starting to have on my body?
A. Your low appetite may be from the inflammation in your body from IBD, or may be due to a complication of the IBD. You should speak with your doctor about whether adjusting your IBD treatment might help your appetite, and whether nutritional supplements would also help.
Q. Can I drink wheat grass juice? I have Crohn's disease and I am thinking about going to a juicing program to get more vitamins.
A. That should be fine. This has been studied in one small study in patients with ulcerative colitis. Just let your doctor know about any supplements to make sure there are not interactions with medications you are taking.
Q. Over the past year I have noticed a nickel to quarter size sore red lump located very close to my bikini area (started as one but have had two at once). It lasts quite a few weeks, is filled with some pus and mostly blood, and leaves a bruise and scar. It is not an STD. I have had Crohn’s for about 20 years and have had a rather large abscess before at the base of my butt cheek. Could this current problem also be related to my illness?
A. Crohn’s disease and ulcerative colitis can be associated with a variety of skin problems that cause inflammation. Sometimes, but not always, these skin problems will be a sign of progressive disease even if there are no or minimal gastrointestinal symptoms. Skin problems that produce swelling, soreness, and pus in and around the groin, under the breast, or under the arms may be due to something called hydradenitis suppurativa. Shaving these areas can worsen these problems. However, given the location of your lump, this may be a sign of a developing fistula. Since the skin lesions are recurring, this should be discussed with your gastroenterologist or treating physician; you might be recommended to see a skin specialist (dermatologist).
Q. Our 2 yr old daughter was diagnosed with Crohn's disease at the beginning of this year. She struggles with constant constipation and has had 2 fecal impactions. Doctors have said there is no particular diet for her to follow... What can help with this constipation? She is a picky eater and sometimes only eats one meal daily. Should she be drinking supplements like Pedisure?
A. In regards to your 2 year old daughter and your concerns about constipation and bowel obstruction there are some helpful dietary modifications I would recommend. First of all, it is very important that she is getting enough calories, protein, fat and micronutrinents, especially calcium, in the diet to promote growth and development. Secondly we would want to make sure she is not consuming foods that would lead to more constipation and risk obstruction. Here are some tips to follow in terms of planning her diet:
1. Homemade shakes made with fortified soy milk, protein powder (like Spiru-tein, found in health food stores)and fresh fruit that is pureed in a blender are great sources of calories, protein, calcium and fat (if you add a tablespoon of peanut butter). I prefer homemade over Pediasure because you can add fresh fruit, like frozen mango, and it is lower in sugar.
2. High antioxidant juices like pomegranate, acai and mangosteen are fabulous sources of nutrition and help to prevent constipation. Try these juices in between meals instead of the typical apple and orange juice.
3. Try to avoid highly irritating fibrous foods like skins, seeds, nuts, popcorn, raw vegetables and high fiber grains while she has inflammation. You should give her cooked and pureed fruits and vegetables to ease digestion and get her the nutrition she needs.Soups and stews are great for meals because everything is well cooked and can be super rich in nutrients.
Q. Our daughter has completed her 10th maintenance round of Remicade and is doing very well. What she fights the most is fatigue - always feeling tired. She still continues her daily schedule as a senior in high school, and seems to get plenty of sleep at night. I know that it is fairly common for Crohn's patients to feel tired much of the time, but I was wondering if there was a suggested supplement or vitamin that she could take to increase her energy level.
A. Fatigue is one of those symptoms that can be secondary to a lot of different things. A lot of time the Crohn’s is blamed, but if the patient is not anemic or actively inflamed it is hard to point to Crohn’s directly. Medications can give you fatigue as a side effect, but many times undiagnosed depression is the culprit. Fatigue can be the body’s response to depression. A thorough physical exploring all of these issues is warranted.
Q. Would going on a liquid diet help to reduce disease symptoms?
A. Studies have shown that a liquid diet (“enteral nutrition”) can reduce symptoms, and reduce inflammation in the intestine. This is a formula prescribed by your doctor which would provide all of your nutritional needs for a period of time – usually 6-8 weeks.
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Q. I had my first UC flare last month, and the second a month later that lasted 3.5 months. After this I had 3 wks of no symptoms and after this the last 2months has been mild symptoms with some diarrhea, a little pain and flatulence. I'm on Lialda and taking a probiotic. What are my current symptoms classified as? Is it a mild flare is this normal for ongoing remission?
A. I would need more information but it seems as though you have mild active disease at this time.
Q. What is the link between Crohns and afib? I was a previously healthy male diagnosed with Crohns in my 70s and developed afib within weeks.
A. To my knowledge there is no correlation. However should your disease be active with diarrhea and you had a tendency for atrial fibrillation, the electrolyte imbalance could trigger A fib.
Q. I have Crohn’s disease. What can cause the stomach to "growl" and "gurgle", loudly and almost constantly? What can be done about it?
A. Malabsorption of carbohydrates can lead to flatus. The treatment is to find out which carbohydrate is being malabsorbed and avoid eating it.
Q. a. I have had an ileostomy for the past 20 years. In the past month it seems that I have become dehydrated due to increase in watery stools. The dehydration is horrible causing severe muscle cramps and spasms all over my body. I have Crohn's diseases and do not remember this happening before. I haven't had a flare of Crohn's since the Ileostomy but I am wondering if it is possible that I am having a flare up.
A. While it is not uncommon to have high ostomy output leading to dehydration, the fact that this is new after 20 years could be several possibilities. To start, this warrants an evaluation with your physician. Questions that would be asked are: have you had a viral gastroenteritis or “stomach bug” in the past couple of months? If so, this will lead to secretory diarrhea (alteration in the “brush border”) and dehydration. Has there been a change in diet/fluid intake? Certain foods/drinks have sugars or even sugar replacements that may serve as a laxative. Have you been on antibiotics recently? This alone may precipitate diarrhea but can also lead to Clostridium difficile (and would be easily checked with a stool sample). Any recent NSAIDs or other new medications? Ultimately, if there is no clear answer to the diarrhea it would be reasonable to undergo testing to determine if there is active Crohn’s ds, i.e. endoscopic evaluation. Finally, it would be very unlikely but a check for celiac disease would be appropriate if all else is negative.
Q. Is there a correlation between colon removal and dry mouth?
A. Yes. The colon serves as a conduit by which fluids and electrolytes are absorbed. In people who have their colon removed, they are more prone to dehydration. Mild dehydration can lead to a dry mouth.
Q. Is it possible that losing 3 teeth (crumbled, broke and fell out); could be a result of continuous vomiting and 5 months of living on TPN due to Crohns? I had 6 surgeries during 5 month hospitalization.
A. Yes. Poor dentition, ie crumbled, broken teeth, is a common problem with Crohn’s disease and especially common in people who have had surgery, shortening of the gut, and vomiting. The reason for this is probably multifactorial, that is, low vitamin and mineral levels, the use of corticosteroids, and possibly the Crohn’s disease itself. Also, in people who have frequent vomiting, this can lead to gum disease and tooth decay as a result of the acid, bile, and other stomach contents. For any patient with Crohn’s disease, regular visits to the dentist is important.
Q. I am recently diagnosed with Crohn's disease. I have extreme bloating/ascities with flareups. Why? I have pain generally to right lower quadrant and lower back but can move around small intestines. I also gain and lose 6 to 8 pounds per month?
A. Ascites (fluid build up within the abdominal cavity) is very unusual with Crohn’s disease and if you are truly having this problem, further testing to identify causes of fluid build up is important. On the other hand, if you are having a sensation of distension and bloating, this may be from several reasons. First, it may be that you are having excess fermentation of intestinal contents due to a condition called bacterial overgrowth. There are definite tests (endoscopy with small bowel cultures, breath test) to diagnose this and treatment is successful with antibiotics. Second, if one has constipation or altered motility (sometimes from inflammation, sometimes unrelated) – that can cause the symptoms you describe. This is simple enough to diagnose with a thorough history, physical examination and in some cases a plain X ray. Gaining and losing weight rapidly may be due to retention of fluid if you are on medications like corticosteroids (prednisone).
Q. I have Crohn’s and now thrush. Can you get thrush from Crohn's or is it just a coincidence?
A. You usually do not get thrush just from Crohn’s but if you are on steroids (prednisone, budesonide) you can get thrush. Also if you are significant malnourished from Crohn’s disease, that can predispose you to thrush.
Q. I have CD and have been on treatment for over two years with Remicade. I still have a lot of everyday symptoms such as loose multiple bowel movements and mouth sores. How do I tell the difference between normal GI issues and ones that I need to report to my Doctor?
A. The best way to tell the difference as to what are unrelated to Crohn’s and those related is to identify which of your symptoms are present at the time of a colonoscopy or MR or CT study demonstrating remission. If you are still having symptoms when these objective tests show remission, then those persisting symptoms are unrelated to active Crohn’s disease. On the other hand if you still have active inflammation, then it is possible that your symptoms may be related to active disease and will respond to modification of your therapy. At other times, a therapeutic trial may be needed (for example, cholestyramine for bile acid diarrhea) to see if your symptoms are from other causes.
Q. I have collagenous colitis. Is this condition an Inflammatory Bowel Disease? Should I simply call it colitis?
A. While collagenous colitis is an inflammatory colitis and can be considered IBD, usually when people use the phrase IBD – they refer to Crohn’s disease or ulcerative colitis. To avoid confusion, I would suggest referring to your condition as microscopic colitis or collagenous colitis (just colitis can suggest other types like ischemic colitis and may be confusing).
Q. I have a hurting under my right ribcage. I have had my gall bladder out and still hurt there. It feels like a fist and hurts from the front to my back. The Dr. sent me for a CAT scan and says I have colitis, although I don't have any of the other symptoms. I would think I would have some of the other symptoms to be colitis. Would a CAT scan show only colon problems?
A. Computerized axial tomography (CAT or CT ) scan uses x-ray and computer technology to create images of the human body. CT scan provides images about internal organs, soft tissue structures, blood vessels, and bone. CT scans are usually completed in sections of the body. To evaluate the region of your discomfort the CT scan is usually of the abdominal location and would show the anatomy of the organs, soft tissue, vessels, and bone in this location. The organs in this location include the stomach, colon, small intestine, liver, spleen, pancreas and kidneys. The information from CT scan along with the clinical picture (your symptoms) usually helps determine the next course of action. I would recommend follow-up with your physician to see if CT findings explain your current symptoms.
Q. The Igg in my blood was over 25. I also have anemia. Colonoscopy, endoscopy, GI series, and MRI all came back normal. I had a lot of diarrhea, until I was put on Entocort EC.
Can you still have Crohn's disease without inflammation showing up on any of the tests?
A. Usually for a new presentation of chronic (>4 weeks) diarrhea and anemia, many potential causes are considered such as include infections, celiac disease, inflammatory bowel disease (Crohn’s or ulcerative colitis). If the anemia is not related, then potential causes are even broader, such as microscopic colitis, endocrine related (hyperthyroidism, low cortisol level) and medications.
Crohn’s disease is defined by having ulceration involving the lining of the intestinal tract and biopsies of the tissue confirming inflammation in a specific pattern. Sometimes it is difficult to locate the area of inflammation due to length of the intestinal tract, > 25 feet long. If none of the tests, including capsule endoscopy, reveal ulceration then another diagnosis for your symptoms should be considered.
Q. I was just released from the hospital after spending four days there. I was admitted because I was having bleeding with bowel movements and also fatigue and nausea. I had a colonoscopy done which showed two ulcers, polyps and that my ulcerative colitis was active. When I was released from the hospital the rectal bleeding has stopped and I started feeling much better. Before I left the doctor ordered a CRP. I got my result today and they showed CRP was 37.9 normal is 0-5. What could this mean?
A. C-reactive protein (CRP) is a protein produced by the liver in response to inflammation. CRP levels can go as high as 200 in the setting of active inflammatory bowel disease and the half-life of the protein is approximately 19 hours. The result of 37.9 suggests that there is still inflammation and likely higher when you initially presented to the hospital. Clinical symptoms improve much faster than markers of inflammation such as CRP and the intestine itself.
Q. Can you explain the relationship between Crohn's and c.difficile infections? The second time I've had c.diff (not a relapse, the last time I had c-diff was 2 yrs ago) and I wasn't using antibiotics prior to the infections either time.
A. IBD, either Crohn's or Ulcerative Colitis, especially involving the colon or large intestine, are well recognized independent risk factors for Clostridium Difficile or C Diff. Hospitalizations and certain medications including immunosuppressive medications and proton pump inhibitors such as Prilosec or Nexium (among many others) may also increase the risk, in addition to antibiotic therapy.
Q. Everything that I read about Crohn's focuses on severe weight loss and diarrhea. My husband was diagnosed years ago with Crohn's but deals with constant bloating, constipation and weight gain. Where is the information on this strain of Crohn's or is it possible that he was misdiagnosed? I don't understand how one disease could look so very, very different in its symptoms and impact.
A. There are different subtypes of Crohn’s which can cause different symptomotology. Patients who have more of an inflammatory subtype often have diarrhea and weight loss, but those with stricturing disease (ie, narrowings in the intestine) can present with more obstructive type symptoms which may include bloating and constipation. Sometimes bloating is associated with bacterial overgrowth as well which can complicate Crohn’s, especially if there’s a stricture. Weight gain is usually not associated directly with Crohn’s, but indirectly can be related, such as when patients are treated with steroids for Crohn’s.
Q. Can your colon look normal after a colonoscopy and still have microscopic colitis?
A. Yes, the colon often looks normal in people with microscopic colitis. That is why it is important to have a high suspicion for this diagnosis and take biopsies from even the normal appearing colon.
Q. I wake up every morning with heartburn. Can the build up of gas in my pouch during the night cause this?
A. Heartburn and pouch related problems are often not related to each other in that people can experience heartburn even when the pouch is normal. However, it is possible that there are problems with emptying of the pouch and build up within, that may lead to more frequent heartburn symptoms. The symptoms should respond to standard treatment for heartburn.
Q. I have a brother who has been diagnosed (possibly incorrectly) with High Fistula. He has had two seton stitches, a plug, and now another flare up with an additional Seton stitch surgery and it has got infected. He is on antibiotics now. Can this be a classic case of Crohns that has gone untreated and been incorrectly diagnosed?
A. Yes, it is possible that some patients may present with perianal fistula first and subsequently develop other signs of Crohn’s disease though this is quite uncommon. If he hasn’t had a colonoscopy, then I would suggest he get a colonoscopy and/or cross-sectional imaging to look for evidence of luminal Crohn’s disease.
Q. I had a small bowel resection done laparoscopically about a year ago. Two weeks ago I had a colonoscopy with anal retroflexion, following which I experienced terrible cramping gas pains and a day later a huge hemorrhoids appeared. A few more days, and I have a hernia at the exact site of the surgery, just above my navel. Could this be caused by excessive pressure from the colonoscopy?
A. Anal retroflexion usually doesn’t lead to significant increase in abdominal pressure. If there have been significant air insufflations during the course of the colonoscopy that can cause crampy gas pains later. Hemorrhoids may sometime be seen after the bowel prep as well due to frequent bowel movements. The hernia at the site of the surgery may sometimes be more prominent after the colonoscopy due to the prolonged nature of the procedure or need for abdominal pressure to navigate the scope.
Q. Is there a high risk of C-diff in ulcerative colitis patients?
A. Yes, there is a higher risk of C diff in ulcerative colitis patients. It is important to test for this infection in the setting of new diagnosis or flare of previously quiet colitis.
Q. I am a 30 year old female currently 14 weeks pregnant. Diagnosed with UC in Feb 2014. My doctor then prescribed prednisone 40mg and tapered to 5 mg over the course of 2 months along with Lialda 2.4 g a day. I went into remission until 13 weeks into pregnancy. My GI doctor has prescribed me Lialda and Rowasa enema. He said that once I go into remission, I should stay on the enema for another month. Just wanted to discuss the safety and the effects on the baby.
A. Mesalamine is a FDA category B agent and is not associated with an increase in birth defects or adverse outcomes. It is compatible with use in pregnancy and lactation. The biggest risk to the pregnancy is actually disease activity which is associated with an increase in preterm birth and perhaps miscarriage as well. Women should continue mesalamine agents in pregnancy if it keeps them in remission.
Q. Has any research been done between Crohn's and taking a daily OTC allergy medication? I was wondering if the anti-histamine would have any impact on the inflammation.
A. There is no data to suggest it would help or hurt.
Q. I had severe Crohn's and a major bowel resection in 1977. Recently my doctor suspects parathyroid tumor because of elevated calcium and PTH levels. Is there a connection to Crohn's or does Crohn's impact these levels?
A. Crohn’s has been associated with low parathyroid levels but I could not find any association with parathyroid tumor.
Q. There was an article in the March the Wall Street Journal about a Swiss small-group study that seemed to correlate flying (and being on the ground above 6500 ft) with flare-ups in IBD , suggesting a correlation between hypoxia and the flare-up. What are your thoughts on this finding? Is CCFA aware of any corroboration of this and whether wearing an oxygen supply while flying might lessen the correlation?
A. The swiss study found an interesting correlation between change in altitude and flares – both mountaineering and plane flights. While oxygen seems to be the obvious culprit, other possibilities including a change in the microbiome with altitude may be the cause. There is no data to support supplemental oxygen being of benefit.
Q. I have ulcerative colitis. It seems no matter what I eat or do, I feel bloated constantly! Right after I go to the bathroom (when I can, that is) I’m still bloated! I use Canasa 1000 mg. I just started taking activated charcoal capsules. Am I going to feel fat and bloated the rest of my life?
A. Bloating may be a sign of many things including a reaction to the Canasa, constipation from the ulcerative proctitis, small intestinal bacterial overgrowth, etc. If you are having difficulty moving your bowels, this is the likely cause of the bloating. However, this difficulty can be because you have inflammation in the rectum blocking the output or, if colitis is under control, can be a more functional issue. You should discuss the possibilities with your doctor.
Q. I am a new Crohn's patient. I hear people talk about flare ups all the time. What does that mean? What do you count as a flare up?
A. The term “flare” can be used to denote several different aspects of Crohn’s disease. The term is best used to describe when a patient is experiencing increased symptoms resulting from Crohn’s disease activity. Symptoms may vary and include those related to intestinal aspects of Crohn’s disease (increased abdominal pain, diarrhea, or blood in the stool) or extra-intestinal features (increased joint pain, Crohn’s-related skin problems). Many of these symptoms can also result from other conditions that frequently coexist with Crohn’s disease, including irritable bowel syndrome (IBS), bacterial overgrowth, Celiac disease, dietary intolerances, or hemorrhoids, just to provide a few examples. Determining whether increased symptoms are due to Crohn’s disease related inflammation (flare) or alternative causes is important as these conditions are all addressed differently. An examination from your physician and targeted testing for evidence of active inflammation will be used to help distinguish if Crohn’s disease is responsible for the increased symptoms.
Q. Is it possible for 6mp 50mg oral daily to cause a man to be sterile? If so would it be beneficial to do sperm banking before starting treatment?
A. Medications such as thiopurines (6-MP mercaptopurine and azathioprine) are not associated with reduced fertility. There is no statistically significant evidence that these medications reduce the viability or quality of sperm.
Q. I have just been diagnosed with Seronegitive Spondyloarthropathy with probable SAPHO. I have had UC for years and have been trying to figure out what all these other symptoms I have had. Four years later and lots of tests we got the answer. Doctors are still working on treatment for me but they say SpA and my colitis go hand and hand. Do you have more information for me on this topic? Are there any members with this combination of these autoimmune diseases?
A. The association of the synovitis, acne, pustulosis, hyperosteosis, and osteitis (SAPHO) syndrome with inflammatory bowel disease has been reported in a few scattered case-reports. The SAPHO syndrome is uncommon and incompletely described. In a recent literature review from an academic center with 62 cases of SAPHO, 4.8% (3/62) also had inflammatory bowel disease (Crohn’s disease or ulcerative colitis). The association is rare, but reported. Many individuals with SAPHO are managed with immunomodulator therapies similar to those used in inflammatory bowel disease. As such, while much more work needs to be done to describe this phenomenon, there is reason to speculate that these conditions may share similar causes, and as such similar treatments.
Q. I was diagnosed with Crohn's in 2008. I have always had joint issues but now it is skin, nails, tendons, and most importantly, issues with my right lung. Problems with my lung have been confirmed by biopsy that it is due to my Crohn's. What can you tell me about lung complications and IBD?
A. Extraintestinal manifestations are common in both Crohn’s Disease and Ulcerative Colitis. However, pulmonary manifestations (while more common in UC) are rare. There needs to be an extensive investigation to other processes before these respiratory tract issues should be attributed to the Crohn’s.
Wegener’s granulomatosis, which is a type of vasculitis (autoimmune inflammation of the blood vessels) often affects the lungs and is characterized by granulomas – a collection and arrangement of white blood cells that is often diagnostic of Crohn’s in the GI tract – and both can co-exist with and be mistaken for Crohn’s disease. Since they are both autoimmune conditions, the possibility of having the two diseases concurrently is strong, and can be associated with positive Proteinase 3-ANCA.
Q. I've been diagnosed with UC, and my symptoms have generally worsened. I am currently taking Uceris, as well as Lialda. I wake up once or twice every night to go to the bathroom, and have urgency in the mornings. Generally, I feel better in the afternoons and evenings. Any research or theories about why my symptoms are worse at night and in the morning? Any suggestions for improving these symptoms?
A. Ulcerative colitis will start in the rectum and progress up the colon. Because of the perianal inflammation, tenesmus (urgency and feelings of having to run back to the bathroom multiple times) is very common. Many patients do in fact have more diarrhea in the morning. It is likely a combination of the once a day medications wearing off as well as a change in the function of the intestines from nocturnal hormonal shifts. Non-IBD patients with Irritable Bowel Syndrome frequently report morning diarrhea as well.
However, IBS patients do not wake up 1-2 times per night. It is always important for stool to be evaluated for bacterial pathogens and C. difficile toxin in the setting of a flare of a UC patient. Absent that, it might be important to have a repeat flexible sigmoidoscopy to assess the state of the mucosa before embarking on therapeutic changes. Sometimes switching mesalamines or combining oral with rectal mesalamine can lead to symptomatic improvement. It is important to talk with your physician about the medications you are currently on and the possible need to switch to a more systemically acting agent.
Q. I’ve had Crohn's for almost 30 year and had a bowel resection surgery about 27 years ago. After surgery I went into remission for 10 years. I am doing Remicade every 4 weeks. I recently had my annual colonoscopy and they have discovered precancerous cells near the resection scar. My doc has recommended another colonoscopy in 6 months, but has not said much regarding the cells. What does this mean for me? How long until the cancer diagnosis comes? What can I do to delay that?
A. Surveillance colonoscopies are performed routinely on all patients with Ulcerative Colitis and Crohn’s disease. While the data are better established for ulcerative colitis, the same is considered to be true for Crohn’s: after having the disease for 8-10 years the risk of neoplasia (either pre-cancer (called dysplasia – which can be high grade or low grade) or cancer) increases by 0.5% - 1% per year above the general population. Factors that have been shown in studies to contribute to and exacerbate that risk include: duration of disease, severity of disease, extent of disease, concomitant Primary Sclerosing Cholangitis, family history of colon cancer.
Anytime that pre-cancerous cells are found in IBD patients in the setting of inflammation, and not in a sporadic polyp (which can be completely removed like a polyp in a non-IBD patient can), there exists the potential for concurrent malignancy or the development and transformation. There is no guarantee that it will transform into cancer but impossible to predict. You should speak to your physician about the risks and benefits of surveillance colonoscopy and surgery.
Q. How common is the C Diff infection for people with IBD?
A. Up to 9% of Ulcerative Colitis patients admitted to the hospital were found to have concomitant C. difficile. It is often more difficult to treat, and with a much greater percentage of patients having recurrent episodes despite antibiotic therapy.
Q. According to recent CT scan my Crohn’s is quiet in my bowel. However, I continue to have joint pain and issues with fatigue. Can it be from the disease or is due to something else?
A. CT scans are fairly accurate in assessing disease activity in patients with Crohn's disease; however they are not perfect.
Fatigue is a common symptom in patients with Crohn's disease. It can be a result of active inflammation, anemia, sleep disturbance, medications, and/or depression. Joint pain is another common symptom in patients with Crohn's disease. There are several types of joint pain in patients with Crohn's disease. Most commonly, patients will have joint pain when there bowel symptoms are active. When the bowel symptoms are controlled by medications, the joint pain should resolve. Similarly, patients can develop arthritis typically involving a large joint such as the knee. This usually resolves when the underlying bowel symptoms are treated. A third form of arthritis involves multiple typically small joints (fingers, hands, wrists) and can occur even when there are no bowel symptoms present.
Further testing is needed to determine whether active Crohn's disease is causing the fatigue and joint pain. This can include additional blood and stool tests and/or endoscopic evaluations.
Q. I was diagnosed May 2014 with UC and I’m taking asocol. I'm having a hard time moving around. Aside from the intense cramping, my lower back hurts more. I don't see many people talk about lower back pain with UC. Is this a symptom or something separate?
A. Low back pain could be related to the ulcerative colitis . About 25% of patients with inflammatory bowel disease develop extraintestinal manifestations of disease. These can include arthritis, particularly an arthritis that affects the spine called ankylosing spondylitis (AS). AS usually presents with significant morning stiffness which gets better throughout the course of the day. Patients can also experience back pain in the upper to lower back. Restricted mobility of the spine is also common and can lead to spinal deformities if untreated. UC patients treated with steroids can experience bone loss called osteoporosis. When osteoporosis involves the spine, spinal fractures can occur, resulting in significant pain. Lastly, UC patients with significant inflammation in the rectum, sometimes report low back pain when trying to have a bowel movement. This should resolve with treatment of the inflammation in the rectum.
Q. I am looking for as much info as I can get on rare extraintestinal symptoms. I have the usual joint, skin, mouth (complete stomatitis) issues. I also have interstitial cystitis, tendon issues. The most concerning is right lung involvement. I have inflammation in my right lung. Open biopsy showed r/t Crohns. Been hospitalized twice for this. On and off steroids for a year. On my 6th injection of methotrexate. I know it's very, very rare. Any info would help.
A. Extraintestinal manifestations occur in up to 25% of patients with inflammatory bowel disease. In general, extraintestinal manifestations (EIM's) are more common in patients with Crohn's disease. Jointpain, aphthous ulcers, and skin problems such as erythema nodosum are the most common EIM's. Occasionally, the tendons surrounding the joints are involved in the arthritis in patients with IBD. There is a link between interstitial cystitis and IBD. Pulmonary problems are commonly encountered in patients with IBD; however these problems are usually related to complications of medications such as infections or adverse drug reactions directly affecting the lungs. Crohn's disease affecting the lungs is rare. I am not aware of guidelines on how to treat Crohn's disease of the lungs although it makes sense that use of systemic agents efficacious for gastrointestinal Crohn's disease would be effective for treatment. I have include a reference that summarizes pulmonary problems in patients with Crohn's disease.
Storch, I., et al. (2003). "Pulmonary manifestations of inflammatory bowel disease." Inflamm Bowel Dis 9(2): 104-115
Q. I have ulcerative colitis. I also have Mitro-valve prolapse and restless leg syndrome. Everything seems to act up all at once. Are these somehow connected?
A. Restless legs syndrome has been associated with Crohn’s disease. In a study by Weinstock et al., the incidence of having restless leg syndrome in Crohn’s disease was high, 42.7%. Crohn’s patients with restless leg syndrome were less likely to have colonic involvement of their Crohn’s and had a history of iron deficiency. Restless legs syndrome has not yet been linked to ulcerative colitis, although several other immune related disorders have been linked to restless legs syndrome, such as multiple sclerosis, rheumatoid arthritis, and Sjogren’s. Restless leg syndrome is also associated with iron deficiency independent of inflammatory bowel disease. In patients with restless legs syndrome, low brain iron concentrations, which may occur even with normal total body stores, have been associated with altered dopamine levels in the central nervous system.
Mitral valve prolapse has not been linked with ulcerative colitis or restless legs syndrome.
Gemignani F.A further cause of secondary restless legs syndrome:Crohn’s disease.Inflamm Bowel Dis. 2010;16: 280-1.
Weinstock L et al.Crohn’s Disease is associated with restless legs syndrome. Inflamm Bowel Dis.2010;16:275-9.
Q. When I flare up my butt sweats so bad that it soaks through to my pants. I tried powder, deodorant and even resorted to Botox. None of those made any improvement. Any information would be appreciated.
A. The excess sweating during flares may be a manifestation of “night sweats”, a common symptom during a flare of inflammatory bowel disease. In a study by Singh and colleagues over 20% of patients had night sweats during a flare. Treatment of night sweats centers on treating the flare itself. There is another condition of excess sweating (hyperhidrosis) that can be generalized or localized (i.e. groin region, axillary region). This condition can be a consequence of medications such as ciprofloxacin and infections. Hyperhidrosis has not yet been clearly linked to inflammatory bowel disease. I suggest you consult a dermatologist for additional guidance for treatment.
Singh et al. Common symptoms and stressors among individuals with inflammatory bowel disease. CGH. 2011;9: 769-75.
Q. I was diagnosed with Crohn's Disease 17 years ago. The first 12 years were ok with, rarely a flare up. The past 4-5 years I've been experiencing many flare ups and problems. In October 2013 I had an Ileostomy surgery. Then last month a surgery to remove 1 foot of intestine. There were plans to reconnect but Dr. was unable to reconnect as there was too much inflammation. Therefore another surgery is planned. I’m worried about all these surgeries. What are the risks of so many surgeries?
A. Any operation on the abdomen is associated with risks during the immediate period following the operation as well as the long-term risk (5%) for blockage of the small bowel secondary to scar tissue creating adhesions. The small intestine is responsible for absorbing nutrients from the foods we consume, and an adequate length of small bowel is needed to ensure that an oral diet can maintain a healthy state of nutrition. In patients with Crohn’s disease, repeated operations to remove segments of the small intestine can result in a condition called short-bowel syndrome that sometimes requires TPN to supplement the patient’s nutrition by direct delivery of nutrients into the blood stream. Although operations for Crohn’s disease are generally avoided unless medical therapy is deemed inappropriate or ineffective for a variety of reasons, several procedures such as strictureplasty can be used as an alternative to removal of the small intestine in an attempt to prevent the development of short-bowel syndrome
Q. Does anyone with Crohn’s Disease get an acidy bad breath? I brush my teeth constantly and I'm always eating breath mints or gum but I still get that smell right before I have a Crohn’s flare up. What can cause the acidy bad breath?
A. Halitosis is a common, but poorly understood, symptom in IBD. There may be several causes for this, eg acid reflux, bile reflux, changes in the microbiome (bacteria in the mouth), medication side effect, a partial blockage of the bowel or poor emptying of the stomach, or possibly an extraintestinal manifestation of the Crohn’s disease. Each of these possibilities requires a different treatment and should be discussed with the treating physician.
Q. I am scheduled to have 5 cm of my ileum removed, which is very small compared to what many people have removed! However, I learned that they are going to remove my appendix at the same time. Why? Is that necessary? What if down the road we find out it is good for something?
A. The last segment of the small intestine (terminal ileum) leads into the first part of the large intestine (cecum) and the junction between the terminal ileum and cecum is called the ileocecal valve. Crohn’s disease commonly affects this terminal ileum and/or cecum. The appendix arises from the base of the cecum and its role is poorly understood.
Q. My GI ordered labs to check for inflammation, and all of the blood work, including inflammation markers, came back in the normal range. But I'm so confused. I had an MRI a week later to check on an abscess and the abscess and the inflammation is still there. Does this mean that blood work can be an unreliable measure of intestinal inflammation? How do you ever know when you're in remission or when it is safe to scale back on medication?
A. Blood tests for inflammation, eg sedimentation rate and CRP, are usually pretty good at detecting inflammation but are not 100%. Sometimes they are elevated when there is no active inflammation in the GI tract and sometimes they are normal in the setting of active IBD. Currently, a deep remission is defined as feeling entirely well but without inflammation. Inflammation, or lack of inflammation, is determined by a composite of tests – blood work, endoscopy, histopathology (from biopsies), and radiography. With regard to when to scale back on medications, that is difficult to answer and there is a lot of research being done on this topic now. Until we have clear parameters and guidelines on whom we can decrease or stop medications, each case is individualized and should be discussed with the treating physician.
Q. I have Crohn’s disease. I have been told that the disease is worse in the descending colon and rectum. The last month I have been having pressure/pain in my rectum with the urge to have a bowel movement. The pressuring is so bad that I have difficulty walking any distances. When I have a bowel movement I strain but the BM is soft. My primary doctor did a rectal exam and said rectum was swollen. Prednisone helped but now I'm off and the pressure is back. What could this mean?
A. Assuming that there is no fistula or abscess, this probably reflects active inflammation from Crohn’s disease. The symptom described is typically referred to as tenesmus, which is an uncomfortable feeling of having to defecate or almost feeling constipated, but there is little relief from a bowel movement. This usually equates to active inflammation. This can be a difficult symptom to treat and either using a topical agent, eg medicated suppository or enema, or “stepping up” to a stronger medication may be required.
Q. Why are the symptoms of UC so intense in the morning? Frequent bowel movements for a 2-3 hour period, with intervals lessening during that time.
A. Motility studies evaluating the rectum in patients with active ulcerative colitis show that rectal inflammation can lead to a sensitive, hyperactive and poorly compliant rectum. When ulcerative colitis is limited to the end part of the colon (rectum and sigmoid) symptoms such as tenesmus are common. Tenesmus is the passage of small stools with a sense of urgency and incomplete evacuation. A likely reason why symptoms are worse in the morning is the change of position from the recumbent position, while sleeping, to a sitting, standing or ambulating position while awake. More debris and fluid likely moves to the end portion of the colon (rectum and sigmoid) with the change in position due to gravity leading to tenesmus . The urgency and frequency may ease once debris from the rectosigmoid region is cleared but may persist if inflammation is severe.
Q. Is the clinical course and progression of ulcerative colitis less severe in Asian patients than in Caucasians? Are cancer risks different or the same in Asian patients?
A. There have been several studies suggesting that Asians have less severe ulcerative colitis and lower colectomy rates compared to other ethnicities. Many of these studies were in non-American Asians, but a recent study from a health care organization in California showed similar results. Asians are a heterogenous group and more data is needed to know about specific ethnicities. More data is needed to know if cancer risk differs from other ethnicities.
Q. I’ve had Crohn’s Disease for 10 years and been on remicade for the last two years. I am fatigued all the time. Are there any foods or vitamins I can take to help boost my energy level?
A. Fatigue may be a consequence of factors related to Crohn’s and the treatment for Crohn’s, but may also not be directly related to the disease. An evaluation to determine the cause for the fatigue is recommended and correcting the underlying cause. An evaluation by your gastroenterologist would typically include evaluation for anemia, malnutrition, and active disease Crohn’s disease which may play a role in causing fatigue. If anemia is present, then vitamin deficiencies should such as iron and B12 can be low in the setting of Crohn’s disease. B12 deficiency may also cause fatigue without having anemia.
Fatigue may not be directly related to Crohn’s. Factors such as hypothyroidism, infection, heart disease, unbalanced diet (in caloric enteric or nutritional value), inadequate sleep and lack of exercise may contribute. I recommend keeping your provider informed of your symptoms to allow for an appropriate evaluation.
Q. What is a neo-end ilestomy?
A. An end ileostomy is created with an operation; the end of the small intestine (ileum) is connected to the abdominal wall and empties into a bag called an ostomy bag. With this arrangement the small intestine is not connected to the ‘downstream’ bowel.
The terminal ileum is the very end of the small intestine where it empties into the colon (large intestine). When part of the terminal ileum has been removed the remaining ileum is sometimes called the neo (new) terminal ileum.
Q. I have had several surgeries. I have had a colostomy/ileostomy and a Hartmann’s pouch since 1989. Just recently, I am having a discharge from my rectum several times each day, and my doctor has no answer. What is causing this? Prednisone seemed to help, while I was on it for two weeks … any ideas?
A. The bowel lining is called mucosa because it secretes mucus. Patients who undergo creation of a colostomy or ileostomy without removal of the rectum can intermittently pass this mucus. Some people will pass mucus a few times each day while others will rarely discharge any mucus; most patients’ frequency is found to occur somewhere between the two extremes. The out-of-circuit bowel can also be inflamed secondary to the patient’s underlying disease or lack of mucosa nutrients normally contained within the waste. This inflammation can cause passage of blood tinged mucus that is usually of little clinical significance.
Q. Does a CT-Scan show Polyps and diverticulitis?
A. CT imaging of the abdomen and pelvis can show either polyps or diverticulitis. A special imaging technique called CT colonography generates three-dimensional images to examine the inside of the colon that is otherwise only seen with colonoscopy. CT colonography is merely a diagnostic procedure, and a colonoscopy is required to remove any identified polyps. CT colonography is sometimes unable to differentiate stool from smaller polyps and may not be as reliable as colonoscopy. Lastly, CT colonography is generally not recommended for patients who have active Crohn's disease or ulcerative colitis because of an increased risk of perforating the colon.
Standard CT imaging is used to diagnose diverticulits, which represent an inflammatory complication of pre-existing diverticulosis.
Q. Is it possible to have two biopsies taken and have one test positive while the other was negative?
A. Yes, it is possible for some of the biopsies taken to show the presence of IBD whereas others can be normal. This is because the distribution of your disease can vary throughout your intestine. As long as there are clear signs of IBD on at least one biopsy that is taken, a diagnosis can be made.
Q. I was prescribed rigevidon as a contraceptive pill and it made me very ill. Is this normal? I have you heard of anyone else being affected by it in this way? Since I came off of it my Crohns seems to have returned. Can the flare up be because of the rigevidon?
A. In general, the evidence of the connection between the oral contraceptive pill and IBD is conflicting. Some studies show an increased risk of developing IBD with oral contraceptive use, while other studies have found no connection. A newer study has demonstrated that women who smoke cigarettes and take the pill for a long time may be at increased risk for developing IBD. Another study found that women who used the pill and already had IBD were not at an increased risk for having a flare-up. Given that there is not enough evidence to conclude that oral contraceptives can cause IBD, you should discuss with your doctor about the side effects that you are experiencing from the oral contraceptive pill. You may require an alternative pill or an alternative form of birth control.
Q. How common is Primary Sclerosing Cholangitis (PSC) and Ulcerative Colitis together or is this IBD a special separate disease entity? Why am I now required to have yearly colonoscopies when my IBD symptoms are mild compared to other people?
A. The prevalence of ulcerative colitis in patients with PSC approaches 90 percent. In addition, there is an increase risk for colon cancer in patients with ulcerative colitis complicated by PSC. Because of this high risk for developing colon dysplasia and cancer in UC patients with PSC, guidelines recommend that patients with both diseases (regardless of their severity) should undergo a surveillance colonoscopy every one to two years from the time of diagnosis of PSC.
Q. What is collagenous colitis? Where can I communicate with others and get more specific information on this disease?
A. Collagenous colitis is a form of microscopic colitis. This means that although your colon looks normal during the colonoscopy, the biopsies demonstrate the presence of colitis. Collagenous colitis is often characterized by chronic, non-bloody, watery diarrhea. In addition to talking to your doctor about the diagnosis and asking for potential patient information, the CCFA also has a handout of information: http://www.ccfa.org/resources/microscopic-colitis.html. One resource to access would be 888.MY.GUT.PAIN.
Q. I have had two colonoscopies. The second they took biopsies. Now my doctor wants to a CT scan. What can a CT scan detect that the colonoscopy did not see.
A. The colonoscopy evaluates the inner lining of the colon and the biopsies taken can determine the presence of IBD. However, the colonoscopy only evaluates the colon but does not evaluate the entire length of the small intestine. Your doctor may have ordered the CT scan to get a better understanding of whether you have small bowel disease and the extent of the disease. CT scans can also be helpful in determining the presence of strictures, fistulae, and abscesses, which a colonoscopy would not be able to evaluate for. It would be important to talk to your doctor about why s/he has ordered the CT scan and what would be the implications of the results.
Q. I was diagnosed with Crohns in Oct 2013 and have been on medication since. I experience gurgling, bubbling stomach noises, followed by pain. Should I be concerned with these noises? What exactly is causing this?
A. Gurgling and audible noises accompanied by pain and bloating, particularly after eating, may be sign of a narrowing in the intestine, which could be related to active Crohn’s inflammation vs scarring from Crohn’s. Sometimes “bacterial overgrowth” can also cause similar symptoms. You should certainly discuss all these issues with your GI doctor.
Q. What is considered a flare? How many times do I have to see blood in the stool before calling the GI.
A. A flare is defined as a recurrence of the typical symptoms that led to diagnosis of ulcerative colitis (UC) or Crohn’s disease (CD). UC symptoms are typically increased frequency/looseness/urgency of bowel movements generally accompanied by bleeding and sometimes with cramps. CD symptoms may vary more but include abdominal pain and diarrhea. Non-GI symptoms such as joint pain may also occur. There is no specific number of times that a symptom (such as blood in the stool) must occur before one calls the doctor, but if the bleeding is severe and/or persistent over several days, you should contact your gastroenterologist.
Q. What is a Neo-end illestomy?
A. An ileostomy is when part of the last portion of the small intestine, or the ileum, is brought out through the abdominal wall, usually in the right lower quadrant and fecal matter is collected in a bag connected to an appliance that fits over the stoma. An “end” ileostomy is usually done when the colon is removed and the ileostomy is most often permanent. A “loop” ileostomy by contrast is generally temporary, with the colon usually being left in place, so that it can “rest” or heal while the fecal matter is diverted through the stoma. “Neo” just means “new” so this might imply that the ileostomy has been redone with a small amount of ileum removed.
Q. Since the onset of my symptoms I have experienced excessive cold sweats that begin as soon as I wake in the morning and continue throughout the day until early evening. I was curious if this is a symptom of UC, or could I be dealing with another issue. My GI does think that is just my body trying to fight the inflammation in me. I do not have a fever when this occurs either. I was wondering if this is a symptom of my UC, and any suggestions for dealing?
A. Excessive sweating would be an unusual symptom of UC in and of itself. Other considerations would be a side effect of steroids, which are commonly prescribed in UC (although should just be used for short term therapy), menopause, low blood sugar, infection, and rarely an early sign of cancer such as lymphoma (but usually they are night sweats and also occur with other symptoms such as weight loss). There is an entity called “idiopathic hyperhidrosis” for which there is no underlying medical cause of the sweating. I would suggest consulting with your primary care doctor as well as your GI doctor. Certainly if your UC is not well-controlled both by symptoms and by colonoscopy, then it’s appropriate to discuss optimizing treatment for your UC. If the sweating were a symptom of the UC, then it should get better/remit when the UC is in remission.
Q. I was diagnosed with left sided UC 4 years ago. I have been on 6mp for 2.5years, and have always been prescribed Prednisone when I flare and it seems to work almost immediately. I have been in a "raging flare" for 1.5months with a co-occurring C-diff infection being treated by Vancomycin. I have constant excruciating pain that even the strongest medications in the hospital can't control. Do you have any advice?
A. You first need to clarify with your doctor whether he/she believes your symptoms at this point are more from recurrent CDiff, active UC or a combination (vs other). This opinion should be informed by CDiff testing, blood work and colonoscopy/biopsies. Depending on the outcome of this discussion/evaluation, other questions to ask: 1) do you need a different/longer treatment for the CDiff? 2) Do you need different treatment for the UC: are you on the right dose of 6-MP? Optimal drug dose is based on weight and how you metabolize the drug (your “TPMT” activity), as well as your white blood cell count and liver enzymes. You might want to discuss with your doctor whether your dose has been “optimized” and whether doing “metabolite” testing to see whether you are on a sufficient dose is possible. If your dose is optimized, then you should talk with him/her about other available therapies for UC. Steroid use should be kept at a minimum.
Q. I was diagnosed with UC at 16 (2010), and the disease quickly ravaged my body. I had a total colectomy, loop ileostomy, and j-pouch. Three years after the surgery, I still have diarrhea. I was told that this isn't unusual, but recently I have noticed blood in my feces. Is this normal?
A. Following a total abdominal colectomy one can consider the option of a J-pouch, which is an attractive option for many compared to a permanent ileostomy. However, one should have appropriate expectations of what is normal and abnormal in the setting of having a J-pouch. The function of the colon is rather straightforward: (1) to reclaim the remaining water and salts not absorbed by the small intestine (1.5-2.0 liters of fluid daily) and (2) to store waste until a socially appropriate time to evacuate the stool. The J-pouch, a pseudo-rectum made from loops of small intestine, serves as a reservoir for waste. However, the J-pouch does not have the absorptive capacity of an intact colon. Therefore, we expect anywhere from 4-8 bowel movements daily in those with a J-pouch. Patients should have adequate control without incontinence, as the anal sphincters are typically unaffected. Several strategies can address the number of bowel movements including the use of fiber products and anti-diarrheals. Bleeding is not normal and should be evaluated. Bleeding could be the result of inflammation in the pouch (known as pouchitis), inflammation at the very short remaining strip of rectum (known as cuffitis), inflammation of the small intestine, or benign conditions like hemorrhoids. All of these conditions are treatable but should be evaluated.
Q. I recently had a colonoscopy. The doctor did endoscopy tattooing. and also removed 5 large polyps. My urine is very blue. How can the indigo ink get into the bladder?
A. What has likely happened is that a small portion of indigo carmine dye was absorbed into a blood vessel and entered the circulation, where it was filtered by the kidneys, collected in the bladder, and then was excreted during urination. This is reported and should not cause alarm. In fact, one of the original uses of this dye was to measure kidney function. It is generally harmless and will clear after a short period of time.
Q. What is a sedimentation rate? Is there a standard level for each person? How is the sedimentation rate lowered?
A. The erythrocyte sedimentation rate is a blood test that can help healthcare providers track inflammation. It is a useful test, measuring the speed of erythrocytes descending through a special collection tube to assess systemic, body-wide inflammation. In IBD, it is essential to monitor inflammation with objective tests, as significant activity may not cause symptoms. Colonoscopy, CT-scans, and MRI are excellent tests for inflammation but they can not be frequently performed because of risk, expense, and inconvenience. ESR is a reasonably priced blood test that is easy to perform and provides non-invasive data regarding inflammation. The limitations of ESR are (1) it may not be elevated even when significant bowel inflammation is present, and (2) it is not specific for bowel inflammation, any inflammation can elevate the level. Despite these limitations, in selected patients ESR can be monitored to reflect how patients are responding to therapy. ESR or CRP that remains very elevated (your doctor will determine whether elevations are due to IBD) may indicate that a change in treatment is needed. In the coming years, more accurate non-invasive markers of bowel inflammation will become widely available, including stool tests of inflammation like fecal calprotectin and lactoferrin.
Q. I have both IBS and IBD (Crohn's) which gives me both digestive and functional problems. Is there any information for people who suffer from both simultaneously?
A. It is now well recognized that all gastrointestinal symptoms in patients with Crohn’s disease may not be due to underlying bowel inflammation, and that a substantial portion of patients with Crohn’s disease additionally fulfill criteria for the diagnosis of irritable bowel syndrome. Fortunately, there does not seem to be any evidence that patients who have both diagnoses do worse in terms of either disease. The key in the management of this is to first rule out Crohn’s disease as a cause of your symptom(s). This is important as IBD is a progressive condition while IBS while impacting quality of life is not associated with progressive bowel damage. Once it has been demonstrating that IBD is in remission, preferably through blood tests, endoscopy, and/or CT or MR imaging, then therapy should be targeted to IBS symptoms depending on the symptom. This could include anti-spasmodics or tricyclic antidepressants for pain predominant IBS, dietary modifications such as the FODMAP diet if bloating is the dominant symptom, or medications to treat diarrhea or constipation.
Q. Why is it that certain Crohn's/UC people get erythema nodosum during flares and some do not?
A. Erythema nodosum is seen in about 3-15% of patients with IBD and is the most common skin manifestation. It has not yet been well established why only some people develop this while others don’t. EN is associated with female gender, colonic Crohn’s disease, smoking, and occurrence of other extraintestinal complications. There is likely a genetic component to this as some studies have associated variants in HLA, PTGER4, and ITGAL with occurrence of EN.
Q. I was just released from the hospital after spending four days there. I was admitted because I was having bleeding with bowel movements and also fatigue and nausea. I had a colonoscopy done which showed two ulcers, polyps and that my ulcerative colitis was active. When I was released from the hospital the rectal bleeding has stopped and I started feeling much better. Before I left the doctor ordered a CRP. I got my result today and they showed CRP was 37.9 normal is 0-5. What could this mean?
A. C-reactive protein (CRP) is a protein produced by the liver in response to inflammation. CRP levels can go as high as 200 in the setting of active inflammatory bowel disease and the half-life of the protein is approximately 19 hours. The result of 37.9 suggests that there is still inflammation and likely higher when you initially presented to the hospital. Clinical symptoms improve much faster than markers of inflammation such as CRP and the intestine itself.
Q. I have been told that my Crohn's has moved to my esophagus. I was looking for info on Crohn’s affecting the esophagus and can’t seem to find info on the subject. I would just like to learn more.
A. Crohn’s limited to the proximal GI tract (esophagus, stomach and first part of the small intestine) represents approximately 5% of affected patients. Esophageal Crohn’s is indeed rare – usually comprising less than 1% of the population with Crohn’s disease. Symptoms include difficulty swallowing (i.e. dysphagia), upper abdominal pain and vomiting. Upper endoscopy often reveals ulcers, redness or erosions. Most patients with esophageal Crohn’s require immunomodulatory or biologic therapy if they do not respond to a short course of steroids. At times esophageal dilation is necessary to overcome strictures within the esophagus.
Q. I have had UC since 2003 and in Feb., 2013 I was diagnosed with Crohn's. But I have read that it is not possible to have both. Is that true?
A. Ulcerative Colitis and Crohn’s are generally described as two separate and distinct diseases with no cross-over or overlap. These two diseases have their own disease symptoms which can differ in terms of history, physical examination, radiography, and endoscopy. We usually teach medical students that they don’t have any overlap at all. However, as we have learned more about what causes IBD and how the body attacks the colon, we see that there are a lot of similarities between UC and Crohn’s. As a result, it might be appropriate to describe someone as “UC-like” or “Crohn’s-like.” While there are some genes that have been shown to be linked to either UC or to Crohn’s, there are more genes that are common to both. Over time, the phenotype (i.e. how the disease manifests clinically) can change. A common scenario is a patient with classic UC who has a total proctocolectomy with Ileal Pouch Anal Anastomosis who later develops a fistula (a sign of Crohn’s disease and not UC). Patients in whom the diagnosis can not truly be labeled as UC or Crohn’s are said to have “Indeterminate Colitis”.
Q. How common is it for Crohn's patients to develop sudden hearing loss due to Auto Immune Inner Ear Disease. I have been battling this for 1 year. There is very little research or information on this topic. Interested in any information out there linking the two conditions and any treatments information.
A. Autoimmune inner ear disease is usually characterized by sudden and rapidly progressive hearling loss in one or both ears. This disease can occur on its own or in association with an underlying autoimmune disorder. As with other autoimmune diseases, it is generally caused by an abnormal and inappropriate immune based attack on the cells of the inner ear (likely in a molecular mimicry fashion where the cells are ‘mistakenly’ thought to be a foreign virus or bacteria). There is no known association with Crohn’s per say, but there have been case reports that this is an extraintestinal manifestation of Crohn’s disease – with findings of granulomas (which are a collection abnormally organized white blood cells that are seen in Crohn’s disease in the GI tract) in the inner ear. Treatment of autoimmune inner ear disease usually consists of immunosuppression by corticosteroids, cytostatic drugs or tumor necrosis factor-α antagonists – the same medications used to treat primary Crohn’s disease.
Q. I was diagnosed with Crohn's disease three years ago. I had pancreatitis, uveitis, and abdominal pain. My doctor started me on Entocort and my fatigue seems a little better. I have uveitis right now and feel like I have a hard time concentrating and I wanted to know if that's due to my uveitis and dry eye or could it be a symptom of Crohn's? I also do not experience the diarrhea that is a common symptom can that happen?
A. The uvea is the middle layer of the eye, just below the sclera. Inflammation of the uvea is called uveitis. Iritis and iridocyclitis are subtypes of uveitis. Uveitis may result in painful, red eyes. This condition is seen in people with Crohn’s disease but is not considered to be Crohn’s involving the eye as uveitis can occur in people without Crohn’s. Painful, red eyes – or any change in vision should be evaluated by an ophthalmologist as soon as possible. Treatment is often with medicated eye drops. Do not assume the symptoms are just from dry eyes. A nice discussion of inflammatory bowel disease associated eye problems can be found on the CCFA website: http://www.ccfa.org/assets/pdfs/eyes.pdf. Not everyone with Crohn’s experiences diarrhea. It depends on the amount of intestine that is involved and the behavior of the Crohn’s. Some people get narrowed areas in the intestine that may actually slow the bowel down.
Q. After an appendectomy about 6 weeks ago, I have suffered the worst UC symptoms I've ever experienced. Is this possibly related to the appendicitis?
A. It is not clear why your UC symptoms worsened after the appendicitis. Perhaps antibiotics were used around the time of the appendicitis, or maybe your UC medication had to be stopped for a while. You should discuss your current flare with your doctor.
Q. I am writing a report on IBD and wish to get information about the number of people with the disease in Connecticut.
A. Two major epidemiological studies on estimates conducted in the United States, one in California and the other in Minnesota. The results for both studies are included in “The facts About Inflammatory Bowel Disease” http://www.ccfa.org/assets/pdfs/ibdfactbook.pdf. Information from these studies as well as information on Connecticut population data will assist you in identifying an estimated number of people with the disease and estimated number of new cases.
Q. Can ulcerative colitis cause small intestinal bacterial overgrowth, or vice versa?
A. Ulcerative colitis is not likely to cause small intestinal bacterial overgrowth. However, it is thought by some researchers that small intestinal bacterial overgrowth may be relatively common, so some people may have both ulcerative colitis and bacterial overgrowth.
There is much ongoing research looking at the role of bacteria in ulcerative colitis. However, at this time, small intestinal bacterial overgrowth is not considered a cause of ulcerative colitis.
Q. I recently had my bowel removed and I am still suffering from joint pain especially on my knees. During my active disease, I took high dosage of steroids and at one point I became "steroid dependant." Is my joint pain still related to my Ulcerative Colitis or is it a side effect from the steroids?
A. a. There are many causes of joint pain in the patient with UC. In your particular situation I would consider the following:
i. Steroid related bone damage. You may have developed osteopenia/osteoporosis so it would be worth having a bone density scan
ii. Steroid withdrawal: this is the most likely scenario. If you were on steroids for a long time, then your body becomes addicted to it and it is very painful to come off them. Withdrawal can result in achy bones and muscles, difficulty getting up out of a chair, fatigue, irritability and depression. You should check with your primary doctor or an endocrinologist to see if you need to come off steroids more slowly
iii. IBD arthritis unrelated to bowel activity: in some patients they have joint pain that is associated with the UC but is independent of it so the inflammation can proceed despite the bowel being out.
b. I would recommend discussing this with your gastroenterologist and perhaps a referral to a rheumatologist is in order
Q. Can you clarify C.diff ?
A. Clostridium difficile is a bacterium that can colonize your colon and cause a host of symptoms from diarrhea to colon inflammation. It is more likely to occur in those who are immunosuppressed or have underlying colon problems like IBD. The use of antibiotics can lead to an attack by destroying the good bacteria in your colon that is keeping the c. difficile in check. Treatment includes the use of probiotics like saccharomyces boulardii, antibiotics such as metronidazole, vancomycin and fidazomicin, and sometimes even surgery. Recently the use of fecal microbiota transplant has shown benefit for hard to treat cases.
Q. What is leaky gut syndrome?
A. Leaky gut is a loose term used to describe hyperpermeability of the gut, or too much space between the cells lining the gut. The consequence of this is that gut contents can more easily seep out into the body and blood stream and potentially cause an inflammatory response.
Q. I have a history of mild colicky pain in abdomen in on and off nature, decreased appetite, low grade fever (20 days), weight loss, weakness for 4-5 months. Examination (colonoscopy and CT scan) suggested IBD (possible crohn's diseae). However biopsies indicates non specific colitis and rule out IBD. I am prescribed sulfasalazine and budesonide tablet. I have 4-6 bowel movement/day but no pain. Please guide if I should get further examination done to confirm diagnosis of crohn's disease.
A. A diagnosis of Crohn’s disease is based on a constellation of findings on endoscopy and pathology. Imaging of the small bowel is usually needed as well to determine the extent of disease. The findings mentioned do not confirm Crohn’s but also do not eliminate it as a possibility. Early in the disease process specific findings on pathology may not be present and over time may change to one that is more specific for Crohn’s. So, a follow-up colonoscopy with biopsies several months later may helpful. There are blood tests (such as saccharomyces cerevisiae antibody) for Crohn’s but there absence does not eliminate Crohn’s as a possibility. Of course, your physician should consider additional diagnoses.
Q. I have had Crohn's disease for 33 years and was recently diagnosed with a high grade retroperitoneal sarcoma. Before surgery I will undergo radiation therapy and am very concerned about how this will affect my IBD. I have not been able to find much information on this topic. Can you direct me some literature or website? Anything would be appreciated. Thanks.
A. In a review by Chon et al, published in the Oncologist, the effects of radiation therapy in patients with inflammatory bowel disease were assessed. The largest study (28 patients) evaluating the effects of radiation to disease activity, 21% has severe acute effects and 29% severe late effects. There was no control group. The risk was higher for late effects in patients without radiation therapy precautionary measures. Precautionary measures included lateral decubitus position, proton beam therapy if available, smaller fields, scheduled rest periods.
Reference: Chon B, Loeffler J. The Oncologist. 2002;7:136-143
Q. Is there a link between geographic tongue and Crohn's Disease?
A. Geographic tongue, also known as benign migratory glossitis, is an inflammatory condition of the tongue that is characterized by discolored regions of taste buds and sometimes even cracks in the surface of the tongue. The lesions can change location, pattern, and size within minutes to hours of forming and patients can have numerous exacerbations and remissions over time. Symptomatic treatments have included fluids, acetaminophen, mouth rinsing with a topic anesthetic agent, antihistamines, any-anxiety medications, tacrolimus, and corticosteroids. Some studies have suggested a link between geographic tongue and oral contraceptive use, diabetes, allergies and other immune hypersensitivities, stress, and psoriasis, but other studies have not supported the same conclusions. There is no literature to support a link between geographic tongue and Crohn’s disease.
Q. What does an elevated alkaline phosphatase indicate? No current flare ups?
A. Alkaline phosphatase is derived predominantly from the liver and bones. Hence the first step in evaluation of an elevated alkaline phosphatase is to identify the source and this can be done through a blood test called a GGT or serum 5’-nucleotidase level. If these tests are also elevated, the source of the elevated alkaline phosphatase is likely from the liver rather than from the bone. The most common causes for a persistant elevated alkaline phosphatase (more than 50% above normal for more than 6 months) include a partial bile duct obstruction, a liver disease called primary sclerosing cholangitis which can be associated with inflammatory bowel disease, primary biliary cirrhosis, certain drugs, and certain infiltrative diseases. Work-up of an elevated alkaline phosphatase can include an ultrasound of your liver, some blood tests, and either an MRI test of the liver or an endoscopic test to look at the bile ducts.
Q. My doctor said I have collagenous colitis, what is the difference between this and ulcerative colitis
A. Collagenous colitis is a form of microscopic colitis that is characterized by chronic, watery diarrhea without bleeding. The colon appears normal by colonoscopy, but biopsies of the colonic mucosa reveal the colitis without any visible ulcerations. In contrast, patients with ulcerative colitis usually present with bloody diarrhea. The colon does not appear normal by colonoscopy and biopsies reveal evidence of chronic inflammation with ulcerations.
Q. Is there a connection between IBD and other inflammation-related disorders—specifically chronic sinusitis (with polyps) and/or Hashimoto's disorder?
A. There is clustering or a connection between inflammatory bowel disease and immune-mediated and inflammation-related disorders. Well-described associations include arthritis (inflammation of the joints), spondyloarthropathy (inflammation of the back), psoriasis (inflammation of the skin), primary sclerosing cholangitis (inflammation of the bile ducts) and episcleritis (inflammation of the white part of the eye) to name a few. More specifically, there is no clear connection between IBD and chronic sinusitis, which often is due to chronic infection and poor drainage of the sinus passages due to allergies or anatomic issues. There is no clear connection between IBD and Hashimoto's thyroiditis based on a large study of over 10,000 people with IBD and 50,000 without IBD.
Q. Will the severity of my flares remain the same for the most part?
A. Several studies have described the natural history of inflammatory bowel disease and whether the severity of flares (inflammation) remain the same for the most part or get better. The most consistent observation is that for most people, flares come and go. There are also groups that start severe and stay severe and some that have mild symptoms the entire time. Thus, while it is hard to predict in any one person, it is common for people to enter a pattern (comes and goes, mostly moderate-severe with little relief, and mild). Fortunately, these patterns of flares can often be broken with appropriate medical therapy. Instead of resigning oneself to chronic symptoms of gut inflammation (pain, diarrhea) and a pattern of severity and flares, it is important to speak with your physician or health care professional and ask what options are available to break the pattern of severity and flares.
Q. There's a group on the internet who are touting "Mycobacterium avium subspecies paratuberculosis" or MAP as a factor in Crohns disease. Is this true information? What's the story?
A. To date there has not been research that substantiates Mycobacterium avium as causative for Crohn’s disease.
Q. My doctor tells me that I have a combination of both Crohn's Disease and Ulcerative Colitis which he is labeling "Crohn's Colitis." Is this possible?
A. Yes, approximately 15% of the time we cannot tell if the inflammation is due to ulcerative colitis or Crohn’s colitis and as such is termed indeterminate colitis.
Q. Is there any guidance for the frequency of having a colonoscopy for someone with long standing Crohn's (30 years)?
A. The major governing organizations in the field of gastroenterology (American Gastroenterological Association and American College of Gastroenterology) have developed recommendations for patients who have ulcerative colitis (UC), with similar guidelines for individuals who have Crohn’s disease involving the colon. These guidelines were developed due to increased risk for colorectal cancer in patients living with ulcerative colitis and Crohn’s colitis and are based on the extent, duration, and age of disease onset.
Individuals who have pancolitis (colonic inflammation in all or most of the colon) should have a surveillance colonoscopy 8 years after diagnosis, and individuals who have left-sided colitis should have a surveillance colonoscopy 15 years after diagnosis. After this initial surveillance colonoscopy, colonoscopy should be repeated every 1-3 years. If a patient has both colitis and primary sclerosing cholangitis (PSC), it is recommended that they have a colonoscopy annually after initial diagnosis.
It is important to have this discussion with your gastroenterologist since guidelines will need to be adjusted based on how the individual is doing. There may be additional things to consider depending on the individual patient, including the degree of inflammation in the colon, any prior history of pre-cancerous changes in the colon prior to, or during diagnosis, and family history.
Q. Could stress cause my daughter to develop IBD or an ulcer? About six months ago she started having "stabbing pains like needles" in her stomach. We have taken her to the doctor repeatedly, he ran blood work, but said everything is "normal." She has weight loss, repeated illnesses, lowered immune. What tests can you recommend?
A. We often blame stress in the development of peptic ulcer disease by increasing the amount of acid produced in the stomach. However, it has been shown that most ulcers in the upper GI tract (stomach/duodenum) are caused either by a specific type of bacteria known as Helicobacter pylori (Helicobacter pylori) or by non-steroidal anti-inflammatory medications (NSAIDS) such as ibuprofen. A person with Crohn’s disease also could develop inflammation and associated ulcers within the entire gastrointestinal (GI) tract, including the stomach and duodenum. The evidence that directly links stress and ulcers is not as clear.
Laboratory studies (i.e. blood and stool tests) can be helpful to check for factors like ongoing inflammation and to evaluate for other things that may feel similar to ulcer-type pain (like inflammation in the pancreas or gallbladder). However, if your daughter already has established IBD, and recently experienced weight loss and other symptoms they may be consistent with an IBD flare, additional testing including endoscopy, additional blood work, and stool tests, may need to be done to better evaluate the intestinal tract. These concerns should be discussed with your primary gastroenterologist to formulate a plan to determine whether your daughter’s symptoms are directly related to her IBD or another medical issue separate from this.
Q. What are the chances of being misdiagnosed with Ulcerative Colitis (UC) and actually having Crohn's disease (CD)? I recently had my colon removed and had a J-pouch created. What are the symptoms to look out for if it is actually Crohn's?
A. When an individual has the “classic” changes associated with CD, including involvement of the GI tract outside of the colon, especially in a part of the small intestine closest to the colon known as the ileum, patchy areas of disease/inflammation known as “skip lesions” (normal, non-inflamed areas of intestine alternating with inflamed/diseased areas), or involvement of the perianal area, the diagnosis of CD is much more clear. Furthermore, there are certain changes when pathologists look under the microscope to look at the biopsies from colonoscopy which may be consistent with CD, and certain types of CD (structuring, penetrating – fistulas) which will be seen either by endoscopy, radiographic studies (i.e. MRI enterography, upper GI series with small bowel follow through), or at surgery.
A patient typically is diagnosed with UC when there is continuous inflammation within the affected colon without involvement in the GI tract outside of the colon (by endoscopy, PillCam study, and radiographic studies), and biopsies show chronic inflammation without the microscopic findings associated with CD. In patients who have to undergo a colectomy (removal of the colon), the removed colon is sent to the pathologist to determine whether the patterns of inflammation or more consistent with UC versus Crohn’s colitis. Even with the rigorous and careful evaluation by your medical team before and after the colectomy, we find that a percentage of patients originally diagnosed with UC actually have CD. Follow-up care with your gastroenterologist and surgeon is important. If you have any symptoms of cramping, diarrhea, bleeding, weight loss, or pain with passing bowel movements, it is important to let them know. Having these type of symptoms does not mean you necessarily have CD rather than UC, but is something that should be investigated to make sure that there are no ongoing issues like pouchitis (inflammation of your J pouch), infection, or issues with the surgical sites.
Q. When my Crohn's disease is flaring, I shake, or vibrate so bad it wakes me up. I'm not diabetic. Is this from Crohn's?
A. Chills or rigors are episodes of shaking or shivering that can be associated with a fever. It is an automatic response that occurs for a variety of reasons, and is often a sign that suggests inflammation or infection such as that seen with active Crohn’s disease. Shivering involuntarily occurs when someone feels cold and acts to raise the body’s temperature. The trigger point at which this response occurs is set in the brain and has been described as an internal thermostat. With inflammation or infection, chemicals called pyrogens reset the trigger temperature. This in turn tricks the body into feeling cold and shaking occurs to raise the body’s temperature.
Q. I was diagnosed with Crohn's about a year ago and by most markers/symptoms I'm in remission yet continue to have periods of fatigue that I didn't have prior to my diagnosis. Is it common/normal to struggle with tiredness even though in every other way I'm fully in remission?
A. Fatigue is a symptom commonly seen in patients with Crohn's disease symptom and can exist for several reasons. While a flare of Crohn’s disease can cause someone to feel fatigued as his or her body is fighting inflammation, fatigue can also occur when the disease is in remission for other reasons such as anemia, depression, or medications. Anemia linked to the decreased production or gradual loss of red blood cells is commonly seen in patients with Crohn’s disease and can lead to fatigue. Chronic diseases such as Crohn’s disease are also often accompanied by emotions such as sadness or depression, and these disorders can cause fatigue. Lastly, fatigue can be a side effect associated with certain medications used to treat Crohn’s disease such as methotrexate, sulfasalazine, and steroids. Any feelings of fatigue should be discussed with a physician so he or she can look for the cause and recommend appropriate treatment. It is also suggested that patients with fatigue eat a healthy diet, exercise on a regular basis, and get an appropriate amount of sleep each night.
Q. What is cause and treatment for black stool?
A. Black stools can occur for a variety of reasons in patients with Crohn’s disease and appropriate treatment depends upon the cause. Certain medications such as iron and bismuth or particular foods that are blue, black, or green colored can also cause black stools. More importantly, black stools can occur because of slow bleeding from inflamed bowel lining; the red blood turns the stool black as bacteria in the stool interact with the blood. The source of bleeding is usually located in the stomach, small intestine, or right colon. Bleeding closer to the rectum or anus more commonly causes the stool to be red instead of black. It is important to discriminate between black stools caused by medications and foods versus bleeding from the bowel wall. This symptom, especially if it is new in onset and persistent, should be reported to a physician so that proper evaluation and treatment can be initiated.
Q. What is the best way to diagnose an adhesion in the small bowel? Should you use small bowel X-Ray series, CT Scan, MRI, and/or colonoscopy?
A. Small bowel adhesions are commonly seen in anyone who has undergone prior abdominal surgery, but adhesions cause difficulties only in a minority of patients. When problems do arise, they are typified by bouts of cramping pain, nausea, abdominal distention, and a change in bowel habits. Patients with Crohn’s disease can experience similar complaints when active disease affects the small intestine. Colonoscopy cannot generally identify small intestine adhesions because the procedure inspects only the inside and not the outside of the large bowel. Imaging studies such as MR enterography and CT enterography are usually more accurate than a small bowel series in their evaluation of the small intestine. However, none of these tests can easily see adhesions. Instead, they identify the consequences of these adhesions such as an abrupt angling or abnormal dilation of the involved bowel. One benefit of MR enterography over the other modalities is that no radiation exposure is required for the test.
Q. What is ulcerative enterocolitis and what part of the small and large intestine is involved? Is it more extensive or serious than pancolitis?
A. The inflammation associated with ulcerative colitis typically begins in the last part of the large intestine and then spreads up the bowel to sometimes affect the entire colon; this complete or near-complete involvement of the large intestine is called pan-colitis. Ulcerative colitis does not usually impact the small intestine unless it is limited to the last few inches in a condition called backwash ileitis.
More extensive inflammation of the small intestine is called enteritis and it is not seen in patients with ulcerative colitis unless they have another disorder such as an infection superimposed on their existing ulcerative colitis. On the other hand, patients with Crohn’s disease can demonstrate inflammation of both the small and large intestine and this is referred to as enterocolitis.
Q. If you are in remission, will there still be signs of disease seen during colonoscopy?
A. Patients with Crohn’s disease may feel completely well but have quite active disease at the time of colonoscopy. For this reason, your medical provider may recommend that you undergo periodic blood work, stool studies or even a follow up colonoscopy to make sure that the inflammation is under control. In patients with ulcerative colitis, there is usually a much stronger correlation between how patients feel and the findings on colonoscopy. Despite that, I estimate that up to 15% of patients with ulcerative colitis will have significant inflammation in the colon even when they feel well.
Q. I am a 31 year old female and was diagnosed with Crohn's Disease in 2004. I had to have a resection in 2008 and have only been hospitalized once since then. I've recently been having a lot of symptoms such as joint pain, intense stomach pain and more frequent bowel movements. I just had a colonoscopy and was told that I have chronic active proctitis. What exactly does this mean for me and will it affect my Crohn's disease? Are the two conditions related?
A. Colitis is a generic term that means inflammation of the colon. Proctitis is a generic term for inflammation of the rectum. Approximately 2/3 of patients with Crohn’s disease will have involvement of the colon and/or rectum; therefore having chronic active proctitis simply means that you have inflammation in the rectum from your Crohn’s disease.
Q. I have no insurance and am unsure if I have IBD. I experience 10-15 bathroom trips per day, sometimes without warning, and stress makes things worse. I've lost weight and sometimes have very bad pain in lower right side. Is there any way to rule out Crohn's disease on my own and/or what should be my next step?
A. Unfortunately, there is no way to exclude Crohn’s disease on your own. Because of the weight loss and the severe abdominal pain, it is important that you are evaluated by a medical provider as soon as possible. I would recommend that you check to see if there are free medical clinics in your area that can begin the evaluation and treatment. In addition, you can call the CCFA Information Resource Center at 1-888-MY-GUT-PAIN to see if there are any medical benefits which you may be entitled to but are not receiving.
Q. I have a history of Crohn's disease in my terminal ileum. Most people that I interact with that have disease in the same area of intestine complain of diarrhea, but I struggle more with constipation. Is there a specific reason why diarrhea was never a symptom for me?
A. Some patients with ileal disease present with diarrhea; however, patients with obstructing or stricturing disease of the ileum present with intermittent abdominal pain, usually after eating. The pain is often with associated abdominal bloating, loud bowel sounds, nausea, and vomiting. At times, patients with obstructive symptoms may feel constipated (also called obstipation). In this situation, patients often feel relief after passing gas or having a bowel movement. Many patients initially present with diarrhea then develop a stricture or blockage over time with a change in symptoms as I describe above. It is also important to note that up to 40% of patients with Crohn’s disease will have superimposed irritable bowel syndrome which can present with constipation as a primary complaint.
Q. I have always had many problems with my stomach for many years. I have thought it was just lactose intolerance, but even if I do not eat or drink any milk products, I still have problems and the pain is getting worse. My new doctor just seen 3 weeks ago says it may be irritable bowel syndrome. She is referring me to a GI for testing to make sure it isn’t Crohn’s. What are the differences between the two diagnoses?
A. There is often a great deal of confusion (as well as overlap) between Crohn’s disease or ulcerative colitis (collectively IBD) and Irritable Bowel Syndrome (IBS). IBD is an inflammatory disease of the bowel where there is an infiltration of white blood cells into the lining of the intestines. This is characterized by endoscopic findings ranging from redness and ulcers to the formation of fistulae (abnormal connections between the bowel and adjacent structures). Bloody diarrhea is the hallmark of ulcerative colitis, as is an urgent need to go to the bathroom with multiple small volume stools a day and having to go to the bathroom at night. IBS has no endoscopic findings and is, at its core, a problem with the function and motility of the bowels itself.
Both diseases can manifest in abdominal pain, discomfort, or change in bowel habits – more likely to be diarrhea than constipation but can be either one in either disease. It is important to determine which disease it is, as the treatments are radically different. For instance, IBD is treated with anti-inflammatory or immunosuppressive medications.
Q. Is mal-odor from the mouth a symptom of active ulcerative colitis? I have been suffering from this condition even before diagnosis with ulcerative colitis and the condition still exists despite my disease being in remission under treatment.
A. Ulcerative colitis is a chronic inflammatory condition involving the colon, characterized by bloody diarrhea, and does not extend into the small bowel or upper GI tract. However, any inflammatory bowel condition can alter the motility of the entire system, and the foul smelling odors you mention may be symptomatic of reflux. If acid or other liquid components from the stomach reach the mouth and gums, disease of the gums and teeth can occur leading to the odor. Be sure to discuss this symptom with your healthcare team.
Q. I have Crohn's and the last couple of weeks I have been using the bathroom more than 15 times a day, and have hardly eaten anything. I have not lost any weight, and all my blood work has come back normal. How is that possible with the lack of food and the constant diarrhea?
A. There are a number of possibilities. Crohn’s disease may be active despite normal blood tests. Some testing may be necessary to determine if the Crohn’s disease is active. Infections can also cause diarrhea. Testing may need to be done in this regard, particularly stool tests. Medications may also cause diarrhea. Have you started any new medications? Have there been any dietary changes? It will also help your doctor to know what you bowel movement frequency was before this worsening. In summary, there are a number of possibilities that your doctor may need to consider.
Q. I was diagnosed more than 10 years ago and have ulcerative proctitis. I find I don't know when it is appropriate to go to the emergency room. What symptoms are of concern? When should I get emergency care for?
A. Generally, proctitis should not cause symptoms that require emergency room evaluation. Small volume bleeding from the rectum and urgent bowel movements can usually be evaluated electively at your doctor’s office. If you have large amounts of bleeding, particularly if you feel lightheaded, or if severe abdominal pain occurs - this is an indication that something different from the proctitis is happening and going to the emergency room is appropriate. If you are not sure, call your doctor’s office or clinic.
Q. I have Multiple Sclerosis and was recently diagnosed with Crohn’s disease. How common is it to have more than one autoimmune disease?
A. It is difficult to give an exact estimate of the likelihood of having multiple sclerosis and Crohn’s disease in the same patient. However, studies looking at this suggest that conditions such as multiple sclerosis occur more commonly (up to two times more likely) in patients with IBD (both Crohn’s disease and ulcerative colitis) than among non-IBD patients. This is also true for other autoimmune conditions such as celiac disease, psoriasis and rheumatoid arthritis in that you are more likely to have these conditions if you have IBD than if you did not. However, it is important to understand that this may just mean that your genetic make-up and environmental exposures predispose you to both these conditions rather that one disease is “causing” the other.
Q. Can you provide information on the epidemiology of ulcerative colitis in adolescents?
A. Overall, the incidence and prevalence of ulcerative colitis appears to be increasing worldwide, but especially in North American and Northern European countries. I’m not aware of studies specifically in adolescents, but there have been studies that have shown a younger age of onset and more frequent diagnosis of UC in younger people. The exact reason for this is not clear and likely has to do with a change in environmental factors, foods we eat, air we breath, and consequent changes in the intestinal flora (microbacteria in the intestines). From my personal experience, ulcerative colitis seems to be occurring in younger patients and presenting with a more severe presentation. Meaning, one day the person is fine and the next they are having severe symptoms – rather than the gradual presentation we often see in adults. We do know that IBD is an immune mediated disease and that the immune system “rev’s up” during adolescence. Therefore, this seems to be a common age of onset of ulcerative colitis and Crohn’s disease. Why there seems to be an increase in IBD at an earlier age is still unknown and likely multifactorial.
Q. My niece has been diagnosed with "probable" Crohn's disease, however her primary symptoms are bloating/gas and constipation. Tests show no inflammation except in the terminal ileum (mild). The IBD Serology Test is negative for IBD and her CRP is going down, yet the constipation persists. Can you give any advice on the status of her diagnosis and what to do next?
A. This is a very difficult and common question. There are many young people who develop gastrointestinal symptoms, e.g. bloating, gas, constipation, and do not have Crohn’s disease or ulcerative colitis. When someone has testing that shows clear cut inflammation, ulcers, and other objective abnormalities, then it is easy to make the diagnosis of Crohn’s. In patients who have a completely normal colonoscopy, blood tests, biopsies, and radiographic testing, we think these patients may have irritable bowel syndrome, rather than Crohn’s disease. Your niece’s case is very common and probably somewhere in the middle. Meaning, her constipation and bloating may be irritable bowel syndrome but it does appear that she has mild inflammation in the ileum and an elevated CRP, which would go along with a diagnosis of IBD. In my practice, when I see patients like your niece, I explain that they may have irritable bowel syndrome and we usually start with that treatment – diet changes, stress reduction (if applicable), and other symptomatic care for IBS. I would then repeat a colonoscopy in one year and if there is no sign of inflammation then I think that while Crohn’s is not impossible, I’d probably favor IBS as the unifying diagnosis. If the symptoms progress or there is more inflammation on repeat testing then this is probably early Crohn’s and treatment should be targeted.
Q. I was diagnosed with UC in 1981 and had a proctocolectomy with permanent ileostomy in 1984. I've been having bouts of diarrhea & constipation for approx. 2 months with severe abdominal pain and bloating. Is it possible to develop IBD again after having my colon removed several years ago?
A. For patients with ulcerative colitis who undergo a total proctocolectomy with end ileostomy it is unlikely, but not impossible to develop IBD again. Generally, a proctocolectomy for ulcerative colitis is a curative procedure. For those patients who have an ileal J pouch reconstruction, it is common to get pouchitis (inflammation of the ileal pouch) from a build up of bacteria. For you, the surgical procedure that you had is technically curative. There are a few reasons I can think of for your symptoms. One is that your ileostomy is beginning to stricture (narrow) at the stoma ending and causing symptoms of constipation, but also bacterial overgrowth. The second is that the changes you are experiencing are related to changes in normal bowel motility. The final is that there is Crohn’s disease – this last possibility is exceedingly rare, and please do not assume this. To sort this out, if you have not had an ileoscopy (scope into the ileum through the stoma) that would be a good start. This would tell you if there is any narrowing/stricture, if there is any inflammation or ulcers, and exclude any other mechanical process to explain the symptoms.
Q. I had a resection in February and was told I have Crohn's. I'm taking 1.875 g a day of mesalamine for remission. My question is why am I having pressure in the center of my chest? I know it is not heart related. I have taken esomeprazole magnesium and other meds with no relief. What can be the cause? Is it from the Crohn's? I am also having back pain in the middle of my back all the time.
A. You need to address this further directly with your doctor. In general, mesalamine is ineffective for the treatment of Crohn’s disease and for prevention of post-operative recurrence so better therapy may be needed. Patients should get repeat colonoscopy around 6 months after surgery to see if the Crohn’s disease has come back and increase treatment based on that. Complications from surgery such as abscess or scarring can cause back pain. Discomfort can also be from heartburn, recurrence of Crohn’s disease and bacterial overgrowth.
Q. I move my bowels more than 6 times a day and then then large clumps of mucus come out rather than stool. What can I do about this?
A. Mucus is not necessarily abnormal. Many women notice an increase in mucus with stools around the time of their menses. The real question is whether your IBD is active. If it is then you need to work with your healthcare team to improve your therapy to reduce the number of bowel movements and reduce any blood or mucus.
Q. I was diagnosed with medication-induced collagenous colitis in 2003. My symptoms resolved after removal of the medication. Currently I’ve experienced 3-4 weeks of diarrhea, cramping, indigestion, fatigue (flu-like feeling). I really have not fully digested food in weeks (moves through system at varying lengths of 15 minutes to 2 hours); even with diphenoxylate/atropine. What could be causing these symptoms?
A. The possible diagnosis for this is infection (there are a lot of viral infections like rotavirus and norvovirus going around), recurrence of collagenous colitis or new development of ulcerative colitis. You should see your gastroenterologist for an evaluation.
Q. I had a total colectomy 10 years ago, but still suffer greatly from constipation, bloating and pain (on my left side and lower left abdomen). I have been back to my surgeon who said it was my diet and then two weeks later it is not my diet (probiotics, tests, scans) still the same. I do not have a colostomy. Is there anything that can be done about my constipation?
A. It is hard to imagine constipation when there is no colon present. This is concerning for some type of stricture or blockage in your bowel or the use of medications, such as narcotics, which slow down the bowel. If there is no physical blockage or medications causing this, then medications that assist bowel movements like osmotic laxatives can be used under the supervision of your doctor.
Q. How commonly are Crohn's disease and/or ulcerative colitis misdiagnosed?
A. It is hard to give a number for this since we don’t truly know the denominator. However, studies do suggest that there is a significant lag time between when patients develop symptoms and when they are diagnosed with IBD – anywhere for 3-12 months. With respect to the reverse, where something is called Crohn’s/UC but is not, we have even less information. Approximately 10% of patients in population based studies never have a recurrence of IBD after their first event. Many of these patients were likely misdiagnosed.
Q. What are diseases other than IBD and intestinal TB that cause chronic bowel ulcers? My 30 year old son has had ileum ulcers since 2008, which have spread to other parts of the digestive tract causing diarrhea and no appetite. He has been treated by 3 GI specialists since 2010 and has taken all medication for Crohn’s and TB, but got worse.
A. Ileal ulceration is a finding seen on endoscopic evaluation (such as colonoscopy or enteroscopy). Stool studies, biopsies of the abnormal region, and blood testing may be needed to determine the cause. There are several potential causes which include Crohn’s and tuberculosis (TB), but also include several other diseases. These diseases include, but are not limited to infections (parasites, bacteria, viruses such as cytomegalovirus in immunocompromised individuals), diseases of immune-dysregulation (eosinophilic gastroenteritis; vasculitis such as lupus and polyarteritis nodoum; vascular ischemia, and tumors (such as lymphoma)). Following up with a GI specialist to understand which diseases have been evaluated for is reasonable. A small percentage of Crohn’s patients are also non-responsive to medical therapy and may require surgery.
Q. Is there any evidence that anabolic steroids can cause and/or inflame ulcerative colitis?
A. There is no data to state whether or not anabolic steroids cause or worsen ulcerative colitis.
Q. I was diagnosed with mild Crohn's (indeterminate) 10 years ago during a hospital stay. After treatment with mesalamine (on two different occasions), the off-on again symptoms lessened within about 2 years. I'm no longer taking meds, but have constant problems with bowel consistency. Could it be I was misdiagnosed? Without currently experiencing symptoms, can any test definitively diagnose IBD?
A. A diagnosis of IBD can be made definitively, but patients may not have all the findings at the time of presentation to make a definitive diagnosis. Findings on testing may evolve over time and may require repeat testing to make a diagnosis of IBD. The findings on endoscopic evaluation (such as colonoscopy/endoscopy) along with the findings on biopsies are the gold standard method for diagnosis. When it is difficult to know whether someone has Crohn’s disease or ulcerative colitis, there are also blood tests that can help differentiate the diseases.
Clinical remission does not always equal endoscopic remission, so it may be worthwhile repeating testing if the diagnosis was not certain from the start.
Additionally, having Crohn’s or ulcerative colitis for more than 8-10 years may increase the risk for colon cancer and colonoscopy (with biopsies) is the recommended screening test.
Q. How can I tell if I have IBS (irritable bowel syndrome) or IBD (inflammatory bowel disease)?
A. While it is possible to have both IBD and IBS, the two disorders can be distinguished by symptoms and by laboratory, x-rays, or endoscopic data. Patients with IBS can have a wide array of symptoms but typically have chronic abdominal pain and altered bowel habits. Patients with IBD who are having a flare often present with increased frequency of bowel movements, rectal bleeding, and abdominal pain. During more severe flares, IBD patients can have fevers, weight loss, laboratory abnormalities, or other manifestations such as inflamed joints or rashes. A colonoscopy, appropriate x-rays, and/or laboratory tests can be done to help determine whether symptoms are from IBD or IBS.
Q. My daughter was diagnosed with mild ulcerative colitis (UC) 2 years ago and has never had blood in her stool until now. Her stool is either soft-formed or very hard, never runny or foul smelling. Could the blood be coming from a tear or hemorrhoids since her stool is hard most of the time when she has the blood? The blood is bright red.
A. It is certainly possible that the bright red blood is due to hemorrhoids, a tear (fissure), or from active ulcerative colitis. You should encourage your daughter to follow up with her gastroenterologist to help determine the source of the blood so that she can receive the appropriate treatment.
Q. What is being done to advance understanding and treatment of anemia in chronic disease (specifically IBD) to maintain a steady state relationship of levels of iron and hemoglobin? Could correct balance improve the immune system and quality of life in IBD?
A. Anemia is a very common problem in IBD. Although many patients report that they do not experience any symptoms from the anemia, many studies have shown that anemia has a significant negative impact on quality of life. The most common cause of anemia in IBD is iron deficiency (related to gastro-intestinal blood loss). Anemia of chronic disease often occurs at the same time due to immune mediated impaired formation of red blood cells and inappropriate iron metabolism. Both oral and intravenous iron therapy have been shown to be effective in treating iron deficiency, and consequently improve quality of life. Another cause for anemia is from a low B12 level. Low B12 levels can develop in patients with active Crohn’s disease or in Crohn’s patients after removal of the terminal ileum (last part of the small intestines).
Q. Is Crohn's a fatal disease and what is the usual time the disease will run its course? My Mother was diagnosed 4 years ago and has had most of her intestines out. It seems to have progressed rapidly - is this a normal course for the disease?
A. Crohn’s disease (CD) is not a fatal disease. Many studies suggest that CD is associated with only a small decrease in overall life expectancy. The typical course for patients with CD includes intermittent worsening of symptoms follow by periods of remission. Patients who have active disease within the past year have a 70% chance of remaining active in the forthcoming year and a 50% chance of being in remission within the following 3 years. Patients can either have mild, moderate or more aggressive disease, and many patients with CD ultimately require surgical intervention. Patients with the more aggressive form of the disease can have earlier return of their Crohn’s disease after surgery and may need more surgery.
Q. Since a few months ago I started to notice cuts behind my ear lobe. It bleeds and gives out liquid and itches a lot. Is this related to the medicine I take or does it have nothing to do with my ulcerative colitis (UC)?
A. Ulcerative colitis (UC) can be associated with a variety of skin problems that cause inflammation. Occasionally, these skin problems can be a sign of progressive disease even in the absence of gastrointestinal symptoms. However, cuts behind your ear lobe seem unlikely to be associated with your UC. Given that these cuts have been occurring for a few months, you should follow up with your physician, who might then recommend you to see a skin specialist (dermatologist).
Q. Why do I have so many body aches and pain that often times will not permit me to walk or stand straight up? I seem to be falling a lot as well.
A. There are a number of things that could be going on to cause your symptoms and you should discuss this with your doctor. Sometimes IBD can be associated with arthritis and this would be at the top of my concerns. If that is the case your doctor may want to send you to see an arthritis specialist and/or choose medications for your IBD that will also help treat arthritis. Arthritis associated with IBD (called spondyloarthropathy) can affect various joints, including the back and pelvis joints and/or the large or small joints of your extremities.
Q. My 16 year old daughter was diagnosed 2.5 years ago with UC. When treating a sore throat/ear infection what antibiotics are safe as to not upset the gut?
A. All antibiotics can upset the gastrointestinal system, in part by changing the gut’s flora, the organisms that reside in the gut. For this reason, antibiotics should be used judiciously, such as when a treating physician is reasonably certain that there is a bacterial infection, as opposed to a viral infection.
Q. Is IBD something you're born with or can you develop it later in life? I recently went to the hospital for severe abdominal pain and diarrhea that lasted 3 weeks. I was dehydrated, but the pain and cramps have persisted for the last 3 months. It bothers me more at night. The only symptom I haven't had is blood in my stool. Should I talk to a GI?
A. Crohn’s disease and ulcerative colitis (collectively IBD) are acquired in life, though their development is under the influence of genetic, as well as environmental factors. Most patients who develop IBD during their lives do so in their late childhood and early adult years, though it may become apparent and become diagnosed any time during life. With your symptoms, I think it would be a good time to schedule an appointment with a gastroenterologist. Your symptoms may or may not be a function of Crohn’s disease or ulcerative colitis.
Q. Is it possible to have IBS in addition to Ulcerative Colitis? My symptoms are so strongly linked to stress and anxiety that I am starting to wonder if it is possible I could have both.
A. It is possible to have both IBS and ulcerative colitis. In most cases, the two disorders can be distinguished by symptoms. Most patients with ulcerative colitis have an increased frequency of bowel movements and rectal bleeding when they experience a flare of symptoms. Patients with symptoms from IBS do not have rectal bleeding. However, stress has been associated with flares of both ulcerative colitis and IBS. When ulcerative colitis patients have diarrhea without blood in the stool, a sigmoidoscopy or colonoscopy can be done to determine whether the symptoms are from ulcerative colitis or IBS.
Q. Can a flare up make you feel hot or even break out into a sweat?
A. Patients with moderate to severe Crohn’s disease or ulcerative colitis can experience systemic symptoms (fever, chills, and/or sweats) during a flare of disease. In addition, patients with complications of their Crohn’s or ulcerative colitis can develop fever. This happens when the bowel or intestine perforates (ruptures) and/or when an abscess (collection of infection) develops. Lastly, the immune suppressant and biologic drugs can predispose patients to infection. A fever in this setting can represent an infection and should be evaluated immediately.
Q. I was diagnosed with ulcerative colitis in 1999. Is it possible to have a flare up where instead of running to the bathroom you have gas with an infection-type smell and sometimes feel like you have a build-up of mucus that gives you a feeling that you want to wipe like when you go to the bathroom?
A. Patients with ulcerative colitis almost always have inflammation in the rectum. When the rectum is inflamed, patients often feel as if they have to go to the bathroom frequently. When patients attempt to move their bowels however, nothing comes out or they pass only blood and mucous. This particular symptom is called tenesmus. Oral or rectal medical therapy can be given for this symptom; if the symptoms improves after therapy it was mostly likely caused by rectal inflammation. Evaluation of the rectum by a sigmoidoscopy or colonoscopy also can be done to confirm the presence of rectal inflammation.
Q. I had a colectomy in January. My doctors thought I had Ulcerative Colitis, so I expected a "cure". A biopsy of my colon showed I actually have Crohn's, so I was told to expect it to recur. I have never had symptoms anywhere but my colon and rectum. I understand there is a type of Crohn's called Crohn's Colitis which only affects the colon. Is there any way to find out what specific type of Crohn's I have?
A. If you have Crohn’s disease involving only the colon (Crohn’s colitis), removal of the colon results in a cure in about 80% of patients. However, if your doctors connect the small bowel to the rectum or if they have done a restorative proctocolectomy (IPAA or J pouch) then it is more likely that the Crohn’s disease will come back. Unfortunately, it is not possible to predict what type of Crohn’s disease you will have. There are some blood tests that can be ordered which can help predict whether your Crohn’s disease will be more aggressive. Unfortunately, this test is often not covered by insurance.
Q. Earlier this year I was diagnosed with ulcerative colitis and about the same time a large amount of proteins were observed in my urine. I recently had a kidney biopsy which came back negative. Is there any research on the effects of UC on the kidneys?
A. It is uncommon or rare for the kidney to be affected in patients with ulcerative colitis. One of the most common drugs used to treat patients with ulcerative colitis, aminosalicylates (or 5-ASA), can rarely cause a kidney injury called allergic interstial nephritis. This usually presents with a decrease in kidney function and inflammatory cells in the urine. In addition, any chronic inflammatory process like ulcerative colitis can cause protein deposition (amyloid) in the kidney. This is extremely rare. Lastly, in patients with small bowel Crohn’s disease, kidney stones can develop which can cause blockage of urine into the bladder. However, this process does not usually result in protein in the urine.
Q. I was diagnosed with ulcerative colitis in 1993 and have a family history of colon cancer. How often should I be getting a colonoscopy? How many years does colorectal cancer take to advance past the early more treatable stages that can be caught in a colonoscopy?
A. The risk of colon cancer in ulcerative colitis depends on multiple factors. Those with disease of the entire colon have a greater risk than those with disease limited to their left colon or rectum. The risk for cancer starts 10 years after the diagnosis, and we think that active inflammation also plays a role in increased risk. A family history of cancer would include first degree relatives under the age of 60 or multiple second degree relatives under the age of 50. You should speak with your gastroenterologist about your specific risk factors in regards to how often you personally need to have a colonoscopy. We believe that the cancer in ulcerative colitis is more aggressive, i.e. grows faster, than cancer that occurs outside the setting of ulcerative colitis, so having colonoscopy in the recommended time frame with attention to a good prep is important.
Q. Is it common to have dry eyes and/or roscia if you have Crohn’s disease?
A. There are several different other autoimmune conditions that one can get if you have Crohn’s disease. Dry eyes and rosacea are two of them. But these can also be side effects of medications.
Q. I’ve had proctosigmoiditis for 25 years and am on 4800mg of mesalamine. Six weeks ago I started having small amounts of mucus and blood in my morning bowel movements. Are small amounts of blood common?
A. Bleeding is a common symptom of active proctosigmoiditis but can also be from hemorrhoids or fissures. If you don’t have other symptoms of active disease, it would be important that that you have the source of the bleeding checked out as it is unlikely the proctosigmoiditis.
Q. I have had a pouch since 1997 because of UC surgery. For the last 3 years my pouchitis has become so chronic that we have tried all antibiotics (resistant now), probiotics and budesonide and now I am on prednisone. It seems that things continue to worsen. What can I do to retain my pouch?
A. It might be that the chronic pouchitis is really Crohn’s disease since you are requiring prednisone to treat it. You should talk with your health care provider about this possibility, as treatment for Crohn’s disease may restore the health of your pouch.
Q. What are strictures and obstructions and how do you know if you have one? Will they always be there until surgery is done or can they heal some with medicine and/or diet? Can you get tested for it and who should?
A. A stricture is a narrowing of the intestine that may or may not cause any symptoms. Strictures can be narrowing from active inflammation (sort of like when your eye can swell shut from pink eye) or from scar tissue. Narrowings can cause obstruction if food or stool is unable to freely pass through this point. Symptoms would include pain, nausea, vomiting and abdominal distention. If in the colon, a stricture can cause constipation. Treatment depends on if the stricture is inflammation or scar tissue, as there are no medications that treat built up scar tissue. Testing for strictures include x-rays and sometimes colonoscopy.
Q. I had a colonoscopy several months ago and had a severe infection in my colon and was treated for this. At my follow-up, I had to be hospitalized due to severe pain and had a CT done and was told had Crohn's. My GI doc still has doubts if it is Crohn's. What else could it be? I had ulcers and inflammation in colon/small intestine.
A. There are many things that can cause inflammation and ulcers in the colon, including infection, medications, Crohn’s disease, certain kinds of cancers, and damage from lack of blood flow. Biopsies from the colon often can differentiate between these different causes. If there is doubt, having more than one expert examine the biopsies can be helpful.
Q. I had a total colorectal removal with a j-pouch formation about 10 years ago. I had problems with pouchitis frequently afterward and continue to have chronic abdominal pain, cramping, and diarrhea. Can someone still have UC after having their colon removed?
A. After total proctocolectomy and ileal pouch-anal anastomosis patients no longer have ulcerative colitis. At surgery all of the colon is removed, except for 1-2 cm of the very end of the rectum near the anus. Although patients no longer have ulcerative colitis, they can continue to have a variety of symptoms that can be similar to ulcerative colitis symptoms, including urgency, frequency, diarrhea, cramping, and rectal bleeding. These symptoms may be due to inflammation in the ileo-anal pouch (pouchitis), inflammation of the remaining 1-2 cm of rectum (cuffitis), Crohn’s disease of the pouch, or irritable pouch syndrome. In addition, scar tissue from surgery (adhesions) or a slow leak from the pouch, with subsequent infection and inflammation, can cause symptoms of abdominal pain and loose stool. A combination of lab tests, radiologic imaging (CAT scan or MRI), and an endoscopy of the pouch (pouchocopy) can help distinguish between these different possibilities.
Q. Should I have a colonoscopy immediately after a severe colitis flare-up or should I wait at least a week or more?
A. It is usually best to wait a couple of weeks after a severe flare-up before doing a colonoscopy, since occasionally the preparation and procedure can worsen the IBD. However, in some situations it is important to do the procedure even during a severe flare-up, so the decision regarding timing of a colonoscopy should be discussed with one’s doctor.
Q. I have had Crohn’s for almost 36 years and had ileostomy surgery last January. I have a hernia in my stoma—is that serious?
A. Stomal hernias are common and are not necessarily serious, especially when small. However, larger stomal hernias may be uncomfortable and can interfere with normal daily activities and normal stoma function. These larger stomal hernias often need surgical repair.
Q. I am currently in a mild flare up and I’m having many problems with joints (big toe, 2nd and 3rd toe). Is there something I can do to lessen the inflammation?
A. The best way to manage the joint inflammation associated with disease flares is to treat the flare itself, thereby decreasing the overall inflammation. However, since improvement in a flare is not always instant, some physicians will treat the pain associated with joint inflammation by adding medications specifically for pain and/or joint inflammation, though it is best to avoid the common over-the-counter anti-inflammatory medications like aspirin, ibuprofen, and naproxen. Additionally, pain focused specifically in the toes, feet, or ankles may be due to another joint disorder like gout or pseudogout, so it is always best to discuss new onset joint pain with one’s physician.
Q. Is suddenly developed eczema after starting a new medication a common side effect?
A. The new development of eczema or any new skin rash is not common with most medications and should be discussed with one’s physician.
Q. I’m 33 years old and have had Ulcerative Colitis for 14 years. I've heard about the symptoms for colon cancer, but wonder how I can differentiate those symptoms from a flare-up?
A. Colon cancer associated with colitis often has no specific symptoms. Some patients have blood in the stools, low blood count (anemia), abdominal pain, loss of appetite, fatigue, nausea, or change in bowel movements. In contrast, an ulcerative colitis flare usually consists of increased numbers of bowel movements, decreased consistency of stools, blood in the stool, urgency and abdominal pain. If you develop any new gastrointestinal symptoms, you should seek a timely evaluation by your medical provider.
Colon cancer in patients with ulcerative colitis is usually diagnosed at the time of a surveillance colonoscopy to screen for pre-cancer (dysplasia) or cancer of the colon. If you have involvement of more than 1/3 of your colon, your risk of colon cancer is increased compared to patients without ulcerative colitis. The risk after 20 years of colitis is about 3% and after 30 years the risk is about 8%. It is currently recommended that you undergo regular colonoscopies for screening after you have had ulcerative colitis symptoms for at least 8 years. If other factors are present such as a family history of colon cancer or primary sclerosing cholangitis, screening may begin earlier. See the CCFA FAQ about Colorectal Cancer and IBD for more information: http://www.ccfa.org/living/colorectalcancer
Q. My daughter has Crohn's and every so often her appendix gets inflamed/enlarged. It is painful for her. Should we have it removed?
A. Management of this problem depends on whether your daughter has appendicitis or whether the appendix is involved with Crohn’s disease. Appendicitis (inflammation and/or infection of appendix) presents with sudden onset abdominal pain, nausea, loss of appetite and fever. Imaging tests such as a CAT scan or ultrasound confirm inflammation of the appendix. Antibiotics are given over the short term followed by surgical removal of the appendix.
Sometimes, Crohn’s disease involving the end of the small intestine (ileum) and beginning of the colon (cecum and ascending colon) can present with symptoms that mimic appendicitis. However, imaging of the abdomen as described above should be able to differentiate between Crohn’s disease and appendicitis in most cases. A colonoscopy is usually performed if it can be done safely to confirm the diagnosis and demonstrate the severity of activity of Crohn’s disease. Management in this case can involve medical or surgical treatment of the Crohn’s disease.
Q. I have had low body temperature (95.5 to 97.6) for several months. Is this something to be concerned about? Could this be related to IBD or to the mesalamine that I'm currently taking?
A. Low body temperature (hypothermia) can be a symptom of severe infection. However, low body temperature from severe infection would not persist over several months. I don’t think that the body temperature readings you are recording are from either your IBD or from the mesalamine.
Q. My son was diagnosed with erythema nodosum. He also has ulcerative colitis. How, if at all, is this related?
A. Patients with Crohn’s disease or ulcerative colitis may develop diseases outside the gastrointestinal tract. These diseases—also called extraintestinal manifestations (EIMs) -- are disorders of the immune system. EIMs usually refer to skin disorders (erythema nodosum and pyodermagangrenosum), eye disorders (uveitis and episcleritis), liver disorders (primary sclerosing cholangitis), and joint disorders (ankylosing spondylitis and certain types of arthritis). Sometimes mouth sores and fevers are included as EIMs. EIMs may or may not mirror IBD activity. EIMs occur in 6-40% of patients, and vary in frequency in patients with Crohn’s disease and ulcerative colitis, and men and women.
Q. I had an ileostomy 6 months ago after 1 bout of suspected colitis and a perforated bowel. Now my doctors are unsure if it was ulcerative colitis or Crohn's. Why can they not tell which it was?
A. Usually Crohn’s disease and ulcerative colitis have distinctive features. Crohn’s disease can involve any part of the intestinal tract from the mouth to the anus, can have areas of intestinal inflammation that are next to normal areas (called “skip” lesions), and inflammation can result in perforation of the intestine. Some Crohn’s patients, but not all, have a unique kind of inflammation called granulomas. Granulomas are seen in biopsy specimens when looked at under the microscope. Ulcerative colitis involves only the colon, and only the very superficial layers of the colon are inflamed, making perforation less common.
In some cases, patients have features of both, making it difficult to make a firm diagnosis. Uncertainty arises in patients with inflammation only in their colon and without granulomas in their biopsy specimens. Disease behavior can also be similar: while intestinal perforation is more common in Crohn’s disease, it can also be seen in patients with ulcerative colitis, especially those with very severe inflammation. Another difficult situation is a patient who undergoes a colectomy for ulcerative colitis and then develops complications, such as abscess or fistula. The physician then must consider whether the complication was because of the surgery or because of underlying Crohn’s disease. Sometimes patients and their physicians may need to observe disease patterns for months to years to make a firm diagnosis. It can still be difficult to firmly distinguish Crohn’s disease from ulcerative colitis. Indeterminate colitis is the term used to describe patients in this situation.
Q. Can you explain what the root cause(s) of Crohn’s disease are?
A. Unfortunately we do not know what the root cause of Crohn’s disease is and this is an important area of research sponsored by the CCFA. What we do know is that it takes several “hits” to get Crohn’s disease. You need to have the right genetic background (though no one else in your family may have Crohn’s), something in the environment that is a trigger for an overactive immune response that can’t turn off (because of your genetic make up). The environmental trigger is likely something different for each patient (virus, bacteria, food, toxins, etc). We are also learning a lot about the human microbiome (the bacteria, virus, fungi that live within us). We are learning that imbalances in this microbiome can be associated with many autoimmune diseases, including Crohn’s disease. This is a simplistic explanation of a very complex and poorly understood interaction, but hopefully ongoing research will better define the issue.
Q. What is the latest in research on using autologous cells to understand Crohn’s disease and potentially find a cure?
A. This is very experimental at this time and much still needs to be learned. Autologous cells are cells that are removed from an individual’s body, cultured, and then reintroduced to the body. There have been some small studies done in severely ill Crohn’s patients who have failed all other therapies with some report of benefit. In Europe, Giorgio Lambertenghi Deliliers, MD has reported on an ongoing trial, called the EBMT Phase III Autologous Stem cell Transplantation International Crohn's disease (ASTIC) trial, that is comparing direct versus delayed (1-year post-mobilization) autologous hematopoietic stem cell (HSC) transplantation. The primary objective of this study is to evaluate the potential clinical benefit of HSC mobilization followed by high-dose immunoablation (which is used to reduce immune resistance) and autologous stem cell transplantation versus HSC mobilization only followed by best clinical practice in patients with CD; the primary end point will be the proportion of patients in sustained disease remission at 1 year.
Q. What are the chances of proctitis changing to colitis? I have pain in my upper colon now and believe it is colitis. Is my pain a symptom of proctitis or could it have grown to colitis? Also, I have been bleeding for 6 wks, is that abnormal? I am currently taking mesalamine with a rectal enema and cannot go to the bathroom and do not have diarrhea.
A. Symptoms of colitis include pain, bloody stools, and frequent loose stools (including night time stools). While ulcerative colitis can affect the entire colon (pancolitis), it may also be limited to segments of the colon, including the rectum. When colitis affects the rectum, or the very end of the colon, it is called proctitis. Some people have only proctitis, and other people may have other areas of their colon affected with inflammation. Patients with proctitis (with or without other areas of colon involvement) will often have a sense of stool urgency, frequency, rectal bleeding, and often pain.
Rectal bleeding for greater than six weeks is not normal, and may reflect inadequately treated proctitis or colitis. Your gastroenterologist will want to discuss these symptoms with you and potentially change your medication. Additionally, change in your stooling patterns, particularly an inability to stool, should be investigated to exclude the development of colon cancer. Your doctor will help you determine the extent of your colitis and if there are any areas in your colon that are worrisome for cancer.
Q. Is swelling in the throat or difficulty swallowing Crohn’s related? I’ve had trouble taking pills and with getting things stuck in my throat for the past year, but I didn't think it was related so I did not mention it to my GI doctor. It is getting worse though and I wonder how concerned I should be and what could help the situation.
A. Difficulty swallowing (dysphagia) is never normal, and in patients with Crohn’s disease, this symptom should be promptly evaluated by your gastroenterologist. There are many causes of dysphagia, including infection, gastroesophageal reflux disease, inflammation of the mouth or esophagus, or development of an esophageal stricture. You should discuss your symptoms with your doctor and your health care team. They may choose to perform a diagnostic x-ray study or perform esophagogastroduodenoscopy (EGD, upper endoscopy) to look at and biopsy any unusual areas in your esophagus.
Q. What damage is caused from a c diff infection with Crohn's disease?
A. Clostridrium difficle infection (CDI) is one of the major causes of antibiotic-associated diarrhea and may represent one of the most common hospital-acquired infections around the world. Patients with inflammatory bowel diseases (IBD) are particularly prone to developing CDI given the higher rates of clinic visits, hospitalizations, antibiotics, and procedures performed. Additionally, some patients with IBD may be at risk for CDI even without antibiotic exposure. Symptoms may mimic or exacerbate an acute flare of either Crohn’s disease or ulcerative colitis, including fever, abdominal pain, nausea, and diarrhea.
Recognition of CDI in patients with Crohn’s disease and ulcerative colitis is important. Diagnosis is made via stool sampling. Once treated, CDI should not be expected to cause permanent damage in patients with Crohn’s disease. Treatment is generally with very specific antibiotics, and most patients have a prompt and complete response. However, progressive CDI can lead to severe colitis and require emergent surgical intervention.
Q. A question about the NOD2 gene and apparent increase in Crohn’s cases. Considering that the incidence is higher in urban areas, is transmissibility possible? If a normally beneficial bacterium’s cell wall receptors have changed and it is transmitted to someone with an abnormal NOD2 gene could it initiate Crohn’s while someone with a normal NOD2 gene would be unaffected?
A. The answer to the transmissibility question remains unknown, but the potential answers are provocative. The precise mechanism that causes Crohn’s disease remains imperfectly understood. However, a common characteristic of IBD is an increased immunological response that perpetuates an inflammatory reaction in the gastrointestinal tract. NOD2 is a gene that regulates gastrointestinal immune and inflammatory response to gut bacteria. Some patients with Crohn’s disease have NOD2 gene mutations; however, not all patients have NOD2 mutations, suggesting that it is a susceptibility factor.
Therefore, in susceptible individuals with an abnormal NOD2 gene, it is possible that an otherwise normally beneficial bacterium or its mutation, its cell wall or byproducts could initiate an abnormal immunological cascade triggering the development of Crohn’s disease. This same bacterium may not invoke an abnormal immunological response in a normal individual.
Q. I am considering moving back to the northern US from the southwest, which is where I was diagnosed (indeterminate colitis). It's common to hear that IBD is more prevalent in northern climates, but that's as much as any source ever says about it. Where does this statement come from and how should I interpret it? Are more people diagnosed there? Do people there flare more often? I am looking for insight to help me decide if moving north is a health risk. I lived there before I was diagnosed.
A. Studies looking at large groups of people have found that diagnosing people with inflammatory bowel disease is more common in northern parts of the world (North America, England, Northern Europe) and less common in other areas of the world like Asia, Africa, and Latin America. Some of this may be complicated by the fact that infectious causes for colitis may mask the diagnoses of IBD in the latter areas. Other studies have found this similar “gradient” of diagnosis within northern countries including the USA and France. However, with the more we know about IBD and with more awareness, these “less common” areas are increasingly diagnosing IBD as well. Of note, these studies are all looking at “prevalence” (how common) and “incidence” (new diagnoses) of IBD and not at how the disease is affected by moving from one climate to another. This latter study is much more difficult to do and less is known.
In regards to how your colitis will do depending on where you live (which is really what you want to know), there is no clear data that moving to the north will lead to more flares than living in the south. While we know there are potential triggers for flare-ups (for example, infections, smoking, non-steroidal anti-inflammatory use), no study has clearly found that moving from one climate to another makes an impact on the course of your colitis.
Q. Will Crohn’s disease or ulcerative colitis ever go away or heal itself?
A. Both Crohn’s disease and ulcerative colitis are chronic inflammatory illnesses that we consider lifelong illnesses. In some cases, however, there is medication-induced healing that is quite durable and spontaneous remission that can be quite durable. Nevertheless, patients are considered to have a lifelong possibility of relapse. This is particularly true in Crohn’s disease when there is quite a high rate of microscopic recurrence after surgery, although much research is being invested into designing ways to avoid such a post-operative recurrence. Surgical treatment of ulcerative colitis results in “loss” of the disease with either the formation of a J-pouch, where a segment of small intestine is attached to the anal sphincters so that patients can still defecate in the usual fashion, or the creation of a permanent ileostomy, in which the small intestine is brought out the abdominal wall and waste is captured by an appliance worn on the abdominal wall.
Q. I was diagnosed in 09 with UC and have not been able to get into remission. Recently I've had severe rectal pain--difficult to change positions, move, and my bowel movements are more painful than ever. It's been 2 weeks. Curiously, my bowel movement frequency had decreased before onset of this pain. A pelvic CT scan was done in ER and visual inspection, nothing found. What could be causing this extreme rectal pain?
A. Rectal pain associated with relative constipation is usually a sign of an anal fissure or small fistula. Visual inspection is usually not sufficient, and they are quite small so will not be seen on CT. An exam by a colorectal surgeon is needed, they can use a special short scope to assess the area.
Q. What happens when a flare up occurs? What should I look out for? My understanding is abdominal pain, diarrhea, and bloody stools. How long do flare ups last?
A. A “flare up” refers to the occurrence of symptoms after a period of no symptoms (remission). Symptoms of a flare up are dependent on which disease you have (UC or Crohn’s disease) and those symptoms you experienced when you got diagnosed. Any persistent change in your bowel habits, blood or pain should trigger a discussion with your doctor as to whether your symptoms are indicative of disease recurrence. The length of a flare up will depend on how long you have symptoms before treatment, the possible reason for the flare, and how bad the disease gets before treatment.
Q. My daughter had a complete colectomy after being diagnosed for UC in 2008. She is doing well, but seems to be prone to colds and flu. She received a flu shot this year. She takes no medication. Are UC patients more prone to colds and flu?
A. Ulcerative colitis patients are not more prone to infections such as Influenza or other upper respiratory illnesses. The flu shot is always a good idea. While not relevant to your daughter’s care, some of the medications that we use often in the treatment of ulcerative colitis can result in an increased risk of infections, however, particularly corticosteroids like prednisone, immunomodulators like 6-merpcaptopurine and azathioprine, and anti-TNF’s like infliximab.
Q. How can Crohn's disease in the stomach be conclusively diagnosed? Could inflammation in the stomach diagnosed as Crohn’s cause severe pain? What is an effective treatment for Crohn’s found in the stomach?
A. Studies have shown that approximately 0.5% to 4% of all patients with Crohn's disease will have involvement of their stomach and/or the duodenum (the first part of the small intestine that comes right after the stomach). Inflammation related to Crohn’s disease can be seen on x-ray studies, such as an upper GI series or through an upper endoscopy with biopsies. But, remember that inflammation can be from other causes, including ulcer disease and/or H. Pylori infection.
Most patients with gastroduodenal Crohn's disease are asymptomatic, but some people will experience epigastric pain, as well as nausea, vomiting, and weight loss.
Treatment for gastroduodenal Crohn’s disease generally includes acid suppression with a proton pump inhibitor. Other medicines can also help, including steroids, 6-MP, and azathioprine. 5-ASA medications are generally not helpful for gastroduodenal Crohn’s disease and the role of biologic therapy remains unclear. In severe cases where a stricture develops and is causing obstruction, this is treated with either endoscopic dilatation or surgery.
Q. I am experiencing lower back pain that stretches across my buttocks and up to waist. Is this part of Crohn's?
A. This kind of low back pain can occur in some patients with Crohn’s disease and will be found to be related to a form of arthritis called sacroiliitis. This condition may be able to be diagnosed by imaging studies, such as a CT scan or MRI. Of course, remember that low back pain is also very common in many people without Crohn’s.
Q. I was diagnosed 14 years ago (at age 22) with Crohn’s disease after a serious case of food poisoning. I have not taken medication for CD in 14 years and have had no disease symptoms since. My colonoscopy over the years show no inflammation. Is it possible that I had a misdiagnosis? Are there new test that should be performed to rule out a misdiagnosis?
A. If you have no symptoms and no other signs of inflammation in the intestine, then it is very likely that you do not have Crohn’s disease. Perhaps there was some transient inflammation due to the food poisoning. There is no need to do any additional tests if you have no symptoms.
Q. I believe the trigger for the onset of my 15 year old son's Crohn's Disease was topical acne medication such as adapalene or clindamycin. Drug warnings indicate that this is a possible cause of Crohn's, but his doctor doesn’t seem to agree. Are doctors tracking the use of acne meds with young Crohn's patients to see if there is a trend?
A. Some recent studies have suggested that an acne medicine taken by mouth was associated with development of Crohn’s Disease. However, other large studies have not shown this. Doctors are tracking the use of acne medications to see if there is a trend.
Q. What is it called if UC is in the cecum?
A. It is still called ulcerative colitis – the cecum is the first part of the colon, where the small intestine, the ileum, empties into the colon.
Q. My daughter just had a terminated colonoscopy due to having friable mucosa throughout her procedure. Is this related to colitis?
A. Yes – friable mucosa means the lining of the colon bleeds easily with contact from the colonoscope. This is because of the colitis.
Q. Can IBD cause bloating in the stomach?
A. Bloating is a very common symptom for patients with IBD. Bloating might be related to the disease, especially if the disease involves the stomach or small intestine. However, bloating might also be related to IBD medications and/or diet. Some foods are very common causes of bloating (and gas), including soda pop, onions and garlic, beans, cabbage, broccoli, cauliflower, and milk products (including ice cream). If the bloating only occurs after eating, and if it is associated with severe abdominal cramps and/or severe nausea and vomiting, it could be a sign of a possible small bowel narrowing in patients with Crohn’s disease.
Q. Before I was diagnosed with Crohn's I had some swelling in my right wrist. I have been on a biologic now for 4 months or so and the doctor told me my Crohn's is in remission. I still have the swelling in my wrist though. I've tried anti-inflammatories and tylenol, but no luck. Is this something that may never go away? My wrist has been swollen for almost 8 months now.
A. IBD can cause a variety of so-called extraintestinal symptoms, including joint swelling and pain. In general, swelling, and often pain and stiffness, of the joints in the arms and legs parallels the activity of the bowel disease. So usually, if the bowel disease gets better with medical treatment the joint disease improves as well. If your joint is still swollen, you should be evaluated by a joint specialist, rheumatologist or orthopedic surgeon, to be certain there is no other problem with the joint.
Q. How does a doctor determine whether a patient has Crohn’s or UC if the disease is located only in the large intestine?
A. This can be difficult. Ten percent of the time we cannot tell the difference and thus diagnose the patient with “indeterminant colitis”. Sometimes there are clues that can go unnoticed, like what appears to be “hemorrhoids” but are really skin tags and signal Crohn’s disease. There are blood tests that can help but these again can be confusing and do not “clinch” the diagnosis.
Q. Is it possible for Crohn's to only manifest in areas of the small intestine that can't be seen by a scope? If so, what is the most effective way to diagnose this and do these alternate methods adequately identify the Crohn's when the symptoms are only mild to moderate in severity?
A. Most patients with Crohn’s disease of the small intestine have signs of the disease in the very last portion of the organ, which can be seen with a scope. CT scans and MRIs are now very sensitive and can pick up abnormalities that previously were missed. As well, video capsule studies (swallowing the pill camera) shows us the entire small intestine. If Crohn’s is present in the middle of the small intestine, there are ways to find it.
Q. How often is ulcerative colitis misdiagnosed?
A. This is a very difficult question to answer as we do not know how many patients fit this category. Ulcerative colitis can be mimicked by many other conditions, and thus it is a combination of tests that lead to the correct diagnosis. An important person in this diagnosis process is the pathologist who is reading the tissue biopsies to see the changes necessary to make the diagnosis of ulcerative colitis.
Q. Two decades now living with Crohn's and being treated with Remicade for years now as no other meds worked in the past. Currently manageable. How often are colonoscopies recommended in my situation? My MD suggests every two years is standard practice, and I would like another opinion on this as I don't want them this often.
A. After having disease for 10 years we recommend surveillance colonoscopies to look for pre-cancerous changes every 1-2 years depending on your other risk factors for cancer. At this time there is no other suitable way to detect these precancerous changes without doing a colonoscopy. Colonoscopies are never fun, but discussing your reluctance to having them can sometimes lead to manageable solutions for your concerns and make the experience less unpleasant.
Q. Why does it take so long to get a clear diagnosis of Crohn’s disease or ulcerative colitis?
A. Many of the symptoms that can lead a patient to a doctor that are from Crohn’s disease or ulcerative colitis can come from a number of different illnesses. Diarrhea can come from infections, medication side effects, deficiencies in numerous processes of digestion and absorption, Crohn’s disease, and many, many other illnesses. The same is true of abdominal pain, weight loss, growth and developmental delays, and so many more of what we call the “presenting symptoms” of Crohn’s disease or ulcerative colitis. To arrive at the diagnosis, doctors must first think of the diagnosis, exclude the other possibilities, and perform a diagnostic test that confirms the diagnosis. Usually, that requires and invasive test, such as a colonoscopy, or a test requiring exposure to X-rays, like a small bowel series or a specialized kind of CT scan called a CT enterography, a kind of X-ray test with specialized computer enhancement. Given a relative hesitation in performing these tests due to patient inconvenience and due to the overlap with other illnesses, it can often take some time to get a clear diagnosis of either Crohn’s disease or ulcerative colitis.
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