Understanding Bowel Obstruction and Intestinal Blockage

DR. ARUN SWAMINATH:

Hi, everyone.

I'm Dr. Arun Swaminath.

I'm the Chief

of Gastroenterology

and the Director

of the Inflammatory Bowel

Disease Program

at Lenox Hill Hospital,

Northwell Health.

Today, we're going to be

answering your most frequently

asked questions about

Crohn's disease.

So let's dive into it.

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What caused my Crohn's disease?

Should I be changing my diet

or lifestyle because of it?

This is one of the hardest

questions and people have been

studying this for many years.

We know there are a lot of risk

factors for Crohn's.

Some of it is genetics,

some of it is environment,

some of it is exposures

that we're not quite sure about.

So there's a lot

of different reasons

a patient may have

an autoimmune disease

of the gut.

Now diet and lifestyle.

These are complex questions

with no easy answers,

but here's where you get

into trouble.

You get into trouble by going

on extreme, limited diets

because you think

that everything is

causing inflammation.

Everything is not

causing inflammation.

And oftentimes you should be

working with a dietician

to make sure that if you are

on a specific diet,

that you're getting

the nutrition and the calories

that you need to stay healthy.

What is a healthy diet?

A healthy diet

in inflammatory bowel disease

is essentially a

Mediterranean diet.

So fresh cooked food,

vegetables, healthy things that

are cooked directly rather

than packages, so you're

avoiding all

of those preservatives

and emulsifiers which can harm

the gut,

and limiting your red

meat intake.

Those are the key things.

What about lifestyle?

It's the same stuff that we

would tell you is healthy,

even if you didn't have IBD,

which is an active lifestyle

where you are not smoking.

Smoking is bad for

Crohn's disease.

And can increase the severity

and increase the likelihood

the medicines you're taking

are not going to work.

So quit smoking.

This is a key thing.

Can someone explain how Crohn's

disease is

different from

ulcerative colitis?

They have a similar root cause.

Well, they're

both under this umbrella

of autoimmune disease,

but Crohn's disease can affect

any part of the GI tract,

so anywhere between mouth

and anus can be inflamed.

And depending on the part

of the body that's inflamed,

people can have very different

symptoms and complaints.

When you take care

of those inflammation, the parts

that heal all of those symptoms

will resolve.

Did anyone else get told it was

IBS for years

before getting

diagnosed properly?

So IBS and IBD

are different things.

IBS is irritable bowel syndrome

and IBD is inflammatory

bowel disease.

Irritable bowel syndrome is

not related

to an autoimmune process.

And we will not find

abnormalities when we

do colonoscopies,

unlike in patients with IBD.

So if a young person comes

and says, hey, I'm constipated,

they're much more likely to have

a diagnosis of IBS than IBD.

So on the odds, it's true

that it's more likely to be IBS.

But what if the young patient

says, I'm more constipated,

but I'm also anemic,

and I'm tired,

and my joints hurt, and I never

felt like this before.

This is not IBS,

and this requires a little bit

more of an investigation.

And I think it's fair to push

and say, hey, I know you're

going to tell me it's IBS,

I've been looking

at these videos

and I've read about this

and I think something is off.

Can we do a little bit more

of an investigation?

It may be simple.

It may be blood tests

and stool tests.

And oftentimes I think it's

really reassuring to do

a stool test like a calprotectin

that basically says, hey,

there's no inflammation based

on the idea

that it's a pretty good test

for looking at inflammation

within the large intestine.

SPEAKER 1: If you've just been

diagnosed with Crohn's disease,

IBD, IBS, or ulcerative colitis,

it can be a super scary time

and there's a lot of

uncertainty involved.

So I wanted to give you guys

the top four things

that I would do if I had

to start all over again.

The first thing is sleep.

And I know this may seem silly,

but your body is in a state

of stress.

You're probably not absorbing

nutrients really well

because you're probably

in a flare and you're probably

super fatigued.

It's totally fine.

It's OK to sleep.

I used to sleep for 16 hours

a day.

I am not kidding.

I am not exaggerating.

I would sleep for 10 to 12 hours

at night

and then take two to three naps

during the day for at least

an hour or two,

I was that tired.

And your body needs this rest.

It's one of the best and easiest

ways to reduce inflammation

in your body, which

is a big problem for you

right now if you're in a flare.

The second thing I would do,

is go on a bit of a reset diet

using some shake or smoothie.

And the one I would recommend

is called absorb plus.

Just do that for a couple

of days, have a couple shakes

a day and see how you feel.

See if that's enough to

reset yourself.

DR. ARUN SWAMINATH: So he's

got a really interesting idea,

and he's really getting

at this idea

of exclusive enteral nutrition

which has been studied

in patients with

Crohn's disease.

Essentially, this

is a liquid diet that has

complex proteins removed from it

to decrease the antigens

that immune system may

respond to.

And what we have found

is that liquid diets,

for some reason,

seem to be better

than solid diets

in the middle of a flare.

Smoothies work, but remember,

smoothies may concentrate sugar

from vegetables,

and having a high sugar load

may increase diarrhea.

So mixing

different consistencies

can be helpful.

Avoiding sugary foods

can be helpful,

and with the dietician

can be super helpful.

And again, partial enteral

nutrition can be

an effective way to help speed

along from a flare

to a healthy state.

SPEAKER 1: The third thing

I would do, is exercise.

Exercise every day.

Now, this doesn't have to be

an intense CrossFit workout.

All I used to do was walk around

my house a few times, do

a couple push ups,

do a couple sit ups, maybe even

do some light yoga

or stretching.

Just movement for even just 10

to 15 minutes

is going to help again, reduce

that inflammation, actually,

as long as it's not too intense

and it's really going to help

with your headspace

because I'm sure you found

if you exercise consistently you

have those endorphins flowing

and you just feel better, which

is going to help your boost

your immune system

and help the overall process

of recovery.

So that's the third thing

I would do.

DR. ARUN SWAMINATH:

Completely agree.

So I think to his point,

you don't need to be

doing CrossFit.

What I love to do

is to recommend to my patients,

get a friend,

go for a walk for 10 or

15 minutes,

get outside, get

a little sunshine

and just be active.

It's easy to sit on the couch

or it's easy to lay in bed,

especially when fatigue is such

a big component of feeling ill.

And you have to fight through

that a little bit to just get

outside and get a little bit

of movement.

SPEAKER 1: And the fourth thing,

honestly, I just want to

tell you,

if you've been told

by the doctors

or by the medical system

that this is impossible to get

over, you'll be on medication

the rest of your life.

Blah blah blah blah blah.

I don't want to disagree

with the doctors there,

but that's just not

the full story.

You can get back

to a total, vibrant,

healthy life.

It is possible.

So keep your head up,

keep trying,

and start with those first three

things I mentioned.

And remember, there is hope.

DR. ARUN SWAMINATH: I really

like what he said.

There is absolutely hope.

And there's more hope now

than there was even 15 years

ago, because the whole landscape

of treatments

has really changed.

I think rather than focusing on

whether you have to be committed

to a drug short term

or long term, the key is to say,

I want to get healthy

and what do I need to do to get

healthy and I will invest

the time and effort to do that?

And that's going to get you

your best quality of life.

Everything after that

is small stuff.

Is it possible to have Crohn's

without super obvious symptoms?

Yes, this is 100% possible.

Crohn's is an autoimmune disease

with inflammation.

Yes, that's true,

but the inflammation is not 100%

on or 100% off all the time.

And what we see over time

in people

is that the inflammation cycles

active and less active.

And so whether patients feel

symptoms from when the time

that they're active or not

can vary patient to patient.

So there may have been people

who for years had no symptoms

and then come to me

with a blockage

or a different type of a

GI complaint.

That's acute.

They end up in the emergency

room and they say,

I have been fine.

And no, I have not had any

of the symptoms

that you've complained about.

And I believe these patients

have probably had inflammation

for years, but it finally became

obvious in a moment

and rather in an extreme way,

unlike most patients, where

they're dealing with symptoms

more chronically and eventually

it gets severe enough for them

to have an investigation

and get a diagnosis.

Does anyone else feel

super overwhelmed

after appointments like you

didn't ask what you really

needed to?

Well, now there are so many

resources for getting educated

and a 15 or 20-minute

appointment with

gastroenterologist it's tough

to answer every question that

you may have.

Oftentimes, most IBD centers

will have

a multidisciplinary team that

can help you.

So there may be a pharmacist

for your questions

about medications.

There may be a dietician

for your questions around diet,

and there may be a nurse

practitioner or a nurse that can

help you deal with other access

questions or questions

about your overall health.

And so using a team like this

is super helpful.

I also highly recommend

the Crohn's and Colitis

Foundation as an organization

that is very patient-focused

and has excellent information

on their website

so that patients can go

and check that out when they're

not under any time pressure.

I also, like most

institutions, have

an electronic medical record

that a patient can access

after their visit.

And so it's important to create

that account.

And you can go back and say,

hey, is this what I remember?

Yes, I remember that I need

to do that

and I'm going to follow through.

So all of those things

can be different resources

for you as a patient.

How often should I be getting

scopes or imaging?

So colonoscopy can be done

for many different reasons.

So if you've started

a new therapy

and we need to prove that it's

helping, oftentimes there will

be a four to six

month gap between starting

a treatment

and doing a colonoscopy.

And we call this doing

a colonoscopy to evaluate

for mucosal healing.

So it's actually looking to see

is the drug doing what we think

it's doing.

Secondly, scopes can be used,

and I'll say scopes

for colonoscopy,

to really figure out if there's

a patient at higher

risk for pre-cancer or

colon cancer.

Patients with inflammation

of their large intestine

may be at risk for higher levels

of precancerous changes.

So unlike the average patient

who starts having colonoscopies

at age 45,

and if everything looks normal,

they have another colonoscopy 10

years later,

patients with ulcerative colitis

often start doing colonoscopies

eight years after diagnosis.

So if you're 20, when

you're diagnosed

with extensive ulcerative

colitis, then it's 28 when you

start your surveillance.

Now, the colonoscopies that come

after that really depends

on what

was found

on that first colonoscopy.

And the range may be between one

year and five years,

depending on what's

actually identified.

Is it true that eating more

fiber can help cure

Crohn's disease?

What's the deal with that?

So right now we don't have

a cure for Crohn's disease,

but what we can do

is get patients

into clinical and endoscopic

remission, which allows you

to have your life back

and to feel good

and to be symptom free.

So that's the goal

with our therapies.

So fiber can be beneficial

because think of it as food

for the bacteria of the gut.

And oftentimes we recommend

fiber in patients

with inflammatory diseases.

Now with Crohn's, patients may

have narrowings

in their intestine called

strictures and fiber.

Think of fiber as creating

a stool that is more bulky

and can have more difficulty

passing through strictures.

So in patients who have Crohn's

and a stricture, we will often

recommend a low-fiber diet.

This will be critical.

In patients who are having

flares, oftentimes we will say

low fiber, low residue,

and let's get you

through the flare

when you're back to normal.

That's when you reintroduce

the fiber overall, as long

as you don't have a stricture.

So this is a question to ask

your GI.

It's a question to ask

your nutritionist as well.

Are there any safe foods I can

eat during a flare?

The answer is yes.

It can be almost as simple

as a BRAT diet.

So white bread, bananas,

vegetables with their skins off,

chicken with their skins

off and cooked well.

All can be

fine during an acute flare,

and you can go back

to your regular diet

once the flare symptoms

have resolved.

SPEAKER 2: If you have Crohn's

disease, here are some ways you

can manage that

through your diet.

IBD you usually have

inflammation in the body,

so you do

want to focus on a lot

of anti-inflammatory foods

and anti-inflammatory teas that

are going to help with this.

Peppermint tea,

chamomile turmeric,

ginger that's all going to help

reduce some of the inflammation

in your body.

DR. ARUN SWAMINATH:

So peppermint is really

interesting because we know

it has an antispasmodic effect.

Peppermint can increase things

like heartburn,

but it can decrease things

like cramping.

So if cramping is a complaint,

peppermint tea or peppermint

supplements could be a really

nice adjunct in the diet.

What does remission even

feel like?

Do you just poop normally again

one day?

And yeah, I think that can

be remission.

And very often I say, the goal

is to get your quality of

life back.

Whether your poop looks exactly

the same as it did back when you

were younger,

or it looks a little different,

probably isn't all

that relevant.

I think what's going to be

the most important thing

as a patient is that you have

control over your stooling

habit, you don't feel anxiety

about going out and living

your life, and you eat what you

want to without having

any trouble,

so that's going to be the goal.

How do you deal with anxiety

around never knowing when

your body is going to

betray you?

So this tells me

that this person really

is feeling insecure about what's

going on with them.

And there's two parts

to this issue.

First, I need to make sure

that the patient is actually

doing well.

Are they

in an endoscopic remission?

And if that's the case,

then I'm going to say I need

the help of my psychologist

or my clinical social worker,

because what we need to do,

is to help get this patient

feeling confident

and to rewire their thinking.

You're well and we need to get

you starting to act well and be

less afraid of what may happen.

Life is all about taking chances

and we want to make sure

that you're enjoying your life

and not feeling like you're too

afraid to do the things that you

want to do.

Is it normal to grieve

the old you after diagnosis?

I think it is absolutely normal,

because I think

that's a big shift from saying,

I never worried about anything

or had to take pills

or treatment or thought

of myself

as a person with a diagnosis

of something absolutely normal.

I think if you're struggling

with this idea or it's bothering

you, you're not sleeping,

you're not feeling yourself,

then this is the time to ask

for help.

And it may be

something as

simple as cognitive behavioral

therapy, which is using

different techniques to help

strengthen the way that

we think,

and to avoid this decline

in circular thinking

and negative thoughts

and other things that might even

require medications or talk

therapy that might require

something a little bit

more intensive.

But it's normal to feel

this way, but it's not

normal to feel this way forever.

Is it normal to feel worse

before you feel better

on steroids

or immunosuppressants?

Absolutely.

Nothing works immediately,

although some people on steroids

can feel better

with that first dose

and that's really reassuring

when that happens.

Immunosuppressants depending

on which medicines

we may be talking about,

the older ones

like mercaptopurine

and azathioprine,

could take eight to 12 weeks

to really work.

Most of our new therapies,

including the biologicals

and small molecule therapies

you may see benefits

within the first few days

or within the first few weeks.

Often I say we think we're

hitting a plateau in that eight

to 12 week mark

after the induction dosing is

done, and that's the time

to reassess whether this drug is

actually helping you.

And if not, what's our plan B?

Do you ever actually reach

remission or is it just managing

symptoms forever?

You can reach remission.

The first step

is clinical remission, meaning

that you feel good.

You're not really complaining

about it when I say what

percentage of normal are you.

And you say 99% to 100%

that's fantastic.

That's the goal.

As a gastroenterologist,

I'm also interested in getting

my patients

into endoscopic remission

because I know that long term,

the outcomes are better.

So when that colonoscopy gets

back to normal,

that's when we're essentially

won the game.

If I have surgery,

can it actually cure Crohn's

disease or is it just

a temporary fix?

So great question.

Surgery does not cure

Crohn's disease.

So surgery can be incredibly

helpful for the right patients.

And I would think of it

as a reset.

If you take the worst part

of the disease out,

all of the other parts

get connected back.

You get your life back

and the symptoms that you were

dealing with often blockages

or pain or other symptoms

like diarrhea or bleeding

can be absolutely addressed.

Depending on the risk factors

for disease recurrence, patients

may often start therapy

at that time point

to prevent the disease

from coming back.

So surgery has fixed a moment

in time.

It does not cure the disease.

For those with kids or planning

to have them, how do you deal

with the guilt and fear

of passing this on to them?

So for patients who have IBD,

I say you should not

feel guilty.

You need to get your disease

under control.

And you say, what's the risk

of passing this on to my kids?

It is less than 10% on average.

It's somewhere between 8% and 9

if one parent is affected

by Crohn's.

And that's pretty good odds.

So 91% that your child will

be healthy.

The other thing to remember,

on the chance that is your child

in the 9%

where they may experience IBD

and what do you need to look

out for?

So oftentimes younger children

will fall off their growth curve

if there's evidence

of inflammation.

And it may not be diarrhea

or other symptoms

that adults experience.

So that may be something

to notify your pediatrician

about so they can keep

an eye on your child as well.

That's all for now.

It's been a pleasure.

If you have any more questions

about Crohn's disease,

feel free to ask them

on social media using

the hashtag Ask WebMD.

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