Constipation

• Constipation is when you have a poo less than three times a week, or less often than is normal for you. Poo is often dry, hard, or lumpy. It may be unusually large or small.
• There are several reasons why you may have constipation if you have Crohn’s or Colitis. Or you may have constipation that is not related to your condition.
• Management includes making sure your Crohn’s or Colitis is as well controlled as possible. Lifestyle changes and laxatives can also help.
• Do not increase the amount of fibre in your diet or take laxatives if you have a narrowing of the bowel (a stricture).

The Bristol Stool (Poo) Chart can be used to assess your poo. The 7-point scale helps describe the shape and texture of your poo. If your poo looks like types 1 or 2, it could mean that you have constipation. Experts generally consider types 3 and 4 to be healthy poos. Type 5 is considered healthy going towards diarrhoea. And types 6 or 7 suggest that you have diarrhoea.

Constipation is when you have a poo less than three times a week, or less often than is normal for you. Poo is often dry, hard, or lumpy. It may be unusually large or small.

Constipation is a less common symptom in people with Crohn’s or Colitis. It occurs in about 1 in every 10 people with Crohn’s or Colitis. It is more common in people with Colitis than those with Crohn’s. Up to 5 in every 10 people with Ulcerative Colitis experience constipation at some point.

Blockage or stricture

Constipation can be due to a blockage in the large bowel. It can also be caused by a narrowing of a section of the bowel, called a stricture. A section of the bowel wall can become narrow due to bowel wall thickening, inflammation, or scarring. This can make it harder for poo to pass through.

Inflammation of the rectum (proctitis)

Inflammation of the rectum (proctitis) is common in people with Crohn’s or Colitis. Severe constipation can be a symptom of proctitis. Other symptoms include the feeling that you need to go to the toilet but your bowel is empty (tenesmus), urgency, and bleeding.

Irritable bowel syndrome (IBS)

IBS is sometimes confused with Inflammatory Bowel Disease (IBD), but is a different condition. IBS can cause similar gut symptoms to Crohn’s and Colitis, including constipation. But it does not cause inflammation of the bowel or bleeding. Some people with Crohn’s or Colitis develop IBS-like symptoms even when their Crohn's or Colitis is under control.

Low-fibre diet

Some people find that high fibre foods can make symptoms of Crohn’s and Colitis worse. Because of this, they may have reduced the amount of fibre in their diet. But high fibre foods absorb water from the large bowel and add bulk to your poo. This makes it easier for poo to pass through your bowel. So, if you have reduced your intake of fibre, you may find that you become constipated.

Low fluid intake

Not drinking enough is a common cause of constipation, even in people without Crohn’s or Colitis. The average adult needs to drink about 6 to 8 glasses of fluids a day. This is around 1.2 litres in total, which equals 6 x 200ml glasses or 8 x 150ml glasses. Water and diluted squash are good choices to stay hydrated. When you are well hydrated, your pee should be a pale-yellow colour.

Small-intestinal bacterial overgrowth (SIBO)

Small-intestinal bacterial overgrowth (SIBO) is a condition where there are more bacteria in the small bowel than usual. This overgrowth occurs when food moves through the gut more slowly than usual. If the bacteria mostly produce methane, SIBO can show as constipation. SIBO is often associated with Crohn’s and Colitis.

Certain medicines

Constipation can be a side effect of some medicines. Common examples include anti-diarrhoeal medicines, iron supplements, and painkillers such as tramadol and co-codamol.

Damage to the anal muscles

Damage to the anal muscles following vaginal childbirth or pelvic surgery.is a common cause of constipation in women.

The evidence for managing constipation in people with Crohn’s or Colitis is poor. It is largely based on the management of constipation in the general population.

Change your toilet position

Changing the way that you sit on the toilet may help to relieve constipation. Try sitting with your knees higher than your hips to help align your rectum. You can do this using a footstool. See the diagram for tips on achieving a better toilet position, to help you relieve constipation.

Food and drink

Changing what you eat and drink can help to relieve constipation in some people. You could try using a food diary or app to find out if any foods affect your symptoms.

Drink plenty of fluids. This helps form softer poo that is easier to pass.

Eating a healthy, balanced diet and having regular meals is usually considered an initial approach to managing constipation. It may help to gradually increase the amount of fibre in your diet. This means eating more foods like fruits, vegetables, grains, beans, nuts and seeds. But some people with Crohn’s or Colitis find that increasing fibre makes their symptoms worse. Increase your fibre intake gradually to reduce wind and bloating. It may take several weeks to see any benefit. Find out more about eating healthily with Crohn’s and Colitis in our information on food.

The British Society of Gastroenterology suggests that a low FODMAP diet may be used to treat bowel symptoms, such as constipation, in people with Crohn’s or Colitis. At the moment, there is not enough high-quality evidence to know for sure if a low FODMAP diet is effective. More research is going on. Find out more about the low FODMAP diet in our information on food.

Exercise

If you can, increasing the amount of physical activity that you do may help to relieve constipation.

Bulk-forming laxatives

Bulk-forming laxatives, such as ispaghula or sterculia, can help to soften hard poo. Again these may not be suitable if you have a stricture, so you should talk to your IBD team before trying these.

Other laxatives

Laxatives can help to relieve constipation. Osmotic laxatives, such as macrogol or lactulose, are usually considered the best type of laxative for people with Crohn’s or Colitis. They increase the amount of water in the bowel so that poo becomes softer and easier to pass. But laxatives can also cause wind and stomach cramps, especially at the start of treatment. Speak to your IBD team before trying laxatives.

Surgery

If you have a stricture that has caused a blockage, you may need surgery. Strictureplasty is a way to repair strictures caused by scarring in the small bowel without having to remove any bowel. Find out more about strictureplasty in our information on surgery for Crohn’s.

If you have a colostomy, you might get constipation. You can help prevent this by:

• Drinking plenty of fluid. Try to drink around 8 to 10 cups a day.
• Eating enough fibre. Aim for five portions of fruit or vegetables a day. High-fibre foods that are easy to digest include bananas, sweet potatoes, and porridge oats.
• Eating regular meals to keep your stoma working well.
• Exercising regularly if you can.

If your constipation does not get better, contact your stoma nurse. They might prescribe medicines to help, or suggest washing out (irrigating) your colostomy.

Find out more about Living with a Stoma.

Overflow diarrhoea

If constipation continues, poo can build up in the last part of the large bowel. This is known as faecal impaction. This can cause tummy pain, bloating, and feeling or being sick. Sometimes the large bowel becomes stretched by the build-up of poo. If this happens watery poo can leak around the solid poo. This often shows as incontinence or soiling of underwear. If left untreated, faecal impaction can cause bowel obstruction or perforation. So, it is important to let your GP or IBD team know if you think you have faecal impaction.

Treatment of faecal impaction includes:

• Laxatives
• Suppositories - you insert a medicine through your bottom
• Enemas - liquid is passed through your bottom into your bowel
• Removal of the poo – a healthcare professional will do this. You should not try to do this yourself

Piles

Some people with constipation may get piles (also known as haemorrhoids). Piles are swellings that contain enlarged blood vessels, found inside or around the anus. Symptoms can include:

• Fresh bright red blood on toilet paper or in the toilet bowl after having a poo
• Itchiness around your bottom
• Soreness, redness, or lumps around your bottom
• Pain or discomfort when having a poo

Symptoms often clear up on their own, or by using treatments available from a pharmacy. If constipation is the cause of your piles, relieving your constipation should help reduce and prevent piles.

Anal fissures

Constipation can cause anal fissures. These are small tears or open sores in the lining of the anal canal. They are most often caused by constipation, when a very hard or large stool tears the lining of the anal canal. Symptoms include:

• A sharp pain when you have a poo. This is often followed by a deep burning pain that may last several hours
• Bleeding when you have a poo. You may notice a small amount of blood either on your poo or on the toilet paper

Most anal fissures get better within a few weeks without treatment, but they can recur if constipation persists.

We follow strict processes to make sure our information is based on up-to-date evidence and easy to understand.

Please email us at evidence@crohnsandcolitis.org.uk if:

• You have any comments or suggestions for improvements
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You can also write to us at Crohn’s & Colitis UK, 1 Bishop Square, Hatfield, AL10 9NE, or contact us through our Helpline: 0300 222 5700