Crohn’s disease is an inflammatory condition that can affect any part of the gastrointestinal tract. Together with ulcerative colitis, Crohn’s is one of the two main types of inflammatory bowel disease (IBD). Crohn’s affects approximately 500,000 Americans and is a chronic, lifelong condition that typically alternates between periods of relatively stable or absent symptoms (remission) and periods of symptom flare-ups that can last for days, weeks, or even months.
The goal of treatment is to induce remission and then to maximize the chance that patients stay in remission. However, almost everyone with Crohn’s disease will experience a flare-up at some point. If you have Crohn’s disease, it is important to understand what you can do to reduce the risk of a flare, to recognize symptoms of a flare, and to manage flares when they do happen.
Flare-ups can be triggered by a variety of factors including changes in diet, new medications, infections and antibiotics, stress, and changes in the underlying disease itself. In some cases a specific trigger can be identified, but in many cases the trigger remains unknown.
Symptoms of Crohn’s disease can vary widely. Some people primarily have abdominal pain and diarrhea, while others may have lack of appetite, nausea, or abdominal distension, and still others may have less specific symptoms such as fatigue, joint pain, mouth ulcers, or eye symptoms.
The key is to have a good sense of your baseline symptoms at remission, and how your Crohn’s disease manifests when it is more active. A number of smartphone apps, including Oshi: IBD tracker and myColitis, can help patients better monitor their condition, prompting you to track things like bowel movements, symptoms, and medications. The Crohn’s & Colitis Foundation has developed an easy-to-use symptom tracker. These types of records can help you provide your gastroenterologist with a more complete picture of your disease activity between office visits.
You should contact your doctor if you think you are experiencing a flare so he or she can test to see if the flare is due to an infection, or determine if any new medications or exposures, such as recent antibiotics, might have triggered the flare. In the absence of infection or another reversible cause of the flare, your gastroenterologist may recommend a treatment course of corticosteroids, either topical (applied to the lower colon through enemas or suppositories) or systemic (body-wide).
Symptom flares can also indicate a change in your body’s response to your current treatment. For example, each year a portion of patients who take either immunomodulator or biologic medications such as infliximab (Remicade) or adalimumab (Humira) stop responding to their medication. Sometimes a major symptom flare can signify that these medications are no longer working. Your doctor can perform tests to confirm if this is the case and, if necessary, switch you to a different medication.
There are a number of additional measures you can take to help manage flares when they do occur.
Avoid NSAIDs. Nonsteroidal anti-inflammatory medications (NSAIDs) like ibuprofen (Advil) or naproxen (Aleve) can impair the ability of the GI tract to protect and heal itself, and can precipitate a flare. If you are having pain, take acetaminophen (Tylenol) instead of NSAIDs.
Quit smoking. Smoking is a strong risk factor for developing Crohn’s disease and can also set off a disease flare. Quitting smoking is strongly associated with fewer flares, decreased medication requirements, and reduced risk of surgery.
Reduce stress. Although stress does not directly cause Crohn’s disease, it does strongly impact IBD symptoms. Many people with Crohn’s disease find the regular use of stress management and stress reduction techniques to be helpful. These can include meditation, deep breathing, biofeedback, yoga, and cognitive behavioral therapy.
Simplify your diet. There is no specific diet that prevents or cures Crohn’s disease, but you may identify specific foods that tend to worsen your symptoms. Keeping a food journal can help you make these connections. There are also several general principles that help most patients feel better when they are experiencing a flare:
- Eliminate dairy.
- Avoid greasy and fried food.
- Limit foods that are high in fiber, such as raw vegetables and whole grains.
- Avoid foods that tend to cause gas (beans, cruciferous vegetables).
- Limit your diet to well-cooked vegetables.
Minimize caffeine and alcohol. They may make symptoms worse during a flare.
Most people with Crohn’s disease will experience a flare at some point, even if they take their maintenance medications as directed. Carefully monitoring and tracking symptoms every day will help you recognize a flare-up when it begins. Let your gastroenterologist know about a flare-up and to be sure to follow recommendations for medications and tests. Dietary and lifestyle modifications can also help manage flare-ups when they do occur.
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“Smoking is strongly linked to the inflammation in Crohn’s disease,” Lee says. It increases the risk of developing Crohn’s disease in the first place and makes symptoms worse once you have it. “It’s very important that smokers with Crohn's disease stop smoking if they can. Because continuing to smoke is associated with disease activity, and patients who smoke after surgery has a chance of getting surgery again,” says Madalina Butnariu, MD, of The Ohio State University Wexner Medical Center in Columbus. Indeed, a study published in 2018 in Frontiers in Immunology reported smoking with Crohn’s disease increases the risk for hospitalization, inadequate response to treatment, and an increased number of surgeries. Quitting can improve your digestive tract’s health along with your lungs and the rest of your body.
2. Eating the Wrong Foods
Eating a well-balanced diet helps manage Crohn’s disease symptoms and prevent flare-ups. According to the Academy of Nutrition and Dietetics, foods high in fiber, fat, dairy products, and carbonated beverages such as soda can trigger a flare-up. Spicy food is another culprit, Dr. Butnariu says. “Most experts suggest a high-calorie diet, especially in those who are losing weight,” Dr. Lee says. But high in calories doesn’t mean high in fat. “Fatty foods are more difficult to digest and can increase diarrhea in people with Crohn’s,” says Richard P. Rood, MD, professor of medicine at Washington University School of Medicine in St. Louis. However, avoiding certain foods increases the risk of malnutrition.“People who live with Crohn’s disease are at a much higher risk of vitamin B12 deficiency, iron deficiency, anemia, and also deficiencies in trace elements like zinc, says Sophie Medlin, RD, a consultant dietitian at City Dietitians and chair for the British Dietetic Association for London.
3. Stressing Yourself Out
It can be stressful not knowing when your next flare-up will occur — and trying to find a bathroom when it happens. “It’s fair to say that not managing your stress and not taking care of your mental health can technically be triggers for Crohn's disease flare-ups,” says Yezaz Ghouri, MD, at the University of Missouri Health Care in Columbia. He says people who are stressed also have sleep problems, which can worsen your health. A study published in May 2019 in Inflammatory Bowel Disease reported people who are stressed out tend to have a poorer quality of sleep, which increases the risk for relapse.
4. Overcaffeinating
Good news for coffee lovers: You don’t have to eliminate coffee altogether — just make sure you’re watching you’re not drinking too much caffeine. “It's no different to if they were someone else who just drank too much caffeine and got diarrhea as a result of it,” says Medlin. “Everybody can get gut symptoms from having too much caffeine, and the reason for that is it speeds up every part of our body, including our small bowel. As a result, things rush through our small bowel a little more quickly, so patients with Crohn's disease may notice that their symptoms are a bit worse if they have excess caffeine.”
5. Overdoing It With Alcohol
Alcohol can interfere with medication used in managing Crohn’s disease and cause nausea and vomiting. This is especially true of the drug Flagyl (metronidazole), Dr. Rood says. A study published in February 2018 in the Journal of Gastroenterology reported patients with Crohn’s disease who drink alcohol also tend to complain of worsening symptoms. Since alcohol disrupts the intestinal tract, the authors recommend against frequent or excessive consumption. No matter what your underlying illness, alcohol in excess is bad, Rood adds.
6. Taking the Wrong Pain Relievers
Nonsteroidal anti-inflammatory drugs (NSAIDs), including Motrin (ibuprofen) and Aleve (naproxen sodium), can worsen the inflammation in Crohn’s disease, according to Lee. If you have pain and want to take something over-the-counter, Lee suggests Tylenol (acetaminophen). Celebrex (celecoxib) also appears to be safe for people with inflammatory bowel disease (IBD) in remission. The Crohn’s & Colitis Foundation recommends using Tylenol for up to 3,000 milligrams per day.
7. Skipping Your Doctor’s Visits
“The most important thing is understanding that Crohn’s disease is a lifelong condition and that patients will need to be followed by a healthcare professional. It’s not something that they have one time, and then it’s gone,” Butnariu says. Crohn’s has no cure, but it can be managed, so getting the right care should always be on your radar. Lee stresses the importance of having a gastroenterologist closely monitor your condition. And make sure to speak to your doctor if you notice any change in symptoms or if you have questions about your condition.
Additional reporting by Jocelyn Solis-Moreira