Running with Crohn’s: Bowel Obstruction!

Running with Crohn’s: Bowel Obstruction

Typical warnings apply.  This entry includes graphic descriptions of biological functions and surgical interventions.

I had a bowel obstruction this week.  This interfered with work (causing me to miss two hours of an important meeting), interfered with running (I missed a 3 mile run), and meant I spent 8 hours traveling on airplanes with severe abdominal pain.  Thank goodness I had left-over hydrocodone to help with that!

Definition

One part of my life with Crohn’s Disease has been suffering from Bowel Obstructions.  A bowel obstruction is a blockage of your intestines that keeps anything else from moving through your bowels.  People without damage to their bowels rarely (if ever) experience these painful issues.

Typically, only people with bowel disease or people who have had surgery on their bowels experience them.  Bowel obstructions usually occur for mechanical reasons; meaning damage to the bowels creates scar tissue that narrows the bowels.  Doctors call this narrowing a “stricture.”

Warning: the following contains graphic descriptions of biological functions.  Some people may find it disgusting.

I possess strictures both from my Crohn’s Disease (because Crohn’s Disease creates ulcerations that over time generate scar tissue) and a small bowel resection performed on me back in 1998.  A normal human small bowel has a diameter of about 1 – 1 ¼ inch.  At least one of my strictures narrows to smaller than 1/3 of that diameter.  The bowel obstruction occurs when a high fiber food item (such as chunks of raw fruits and vegetables) successfully passes through the rest of my bowels but cannot pass through this narrow stricture.  This is very much like a clogged drain or toilet.  Once blocked, nothing else can pass through my bowels without first removing whatever caused the clog.

Image of a stricture cause by active Crohn's Disease.  Strictures due to surgical scaring have a different appearance.  Note, the abscess in the upper right of the image, this is how my fistulas begin. However, my fistulas occur in my lower GI tract near or in my anus.

Strictures internal to the intestines due to adhesions (lighter fibrous strands).  Typically these form after surgery.  They account for 50%-70% of intestinal strictures.

Symptoms

When I am suffering from one of these “episodes”, I experience many symptoms:

• Intense sharp pain, as if I am being stabbed repeatedly by knives in the gut
• Obvious bloating of my abdomen, so that sometimes I look like I am 7-8 months pregnant
• Intense cramping, that feels slightly different from my normal Crohn’s cramping (it has a slightly sharper edge to the pain) and different from the sharp pains described above
• Hardening of the abdominal muscles until they feel almost rigid
• I also experience very full feeling as if I ate an extremely large meal.  With this, I sometimes experience severe nausea that may or may not result in vomiting.  Often this feeling makes the thought of eating very repulsive, even if I have not eaten for a day or more
• A full gut feeling like you need to poop, but I am not able to.
• A general sense of trauma in my abdomen that makes me want to not bounce around (I do not want to run or jump!).
• A general sense of anxiety or unwellness – sometimes accompanied by a light sweat.

The pain from a bowel obstruction can be (but for me is not always) excruciating, so excruciating in my case that I sometimes require hospital grade pain killers – which I can only get through admittance into the emergency room.  However, after experiencing 1-6 bowel obstructions per year for the last 15 years or so, I now rarely seek admission to the hospital.

Warning: I am not a medical professional, if you suspect you are experiencing a bowel obstruction and are not familiar with the symptoms, get yourself to an emergency room and get evaluated as soon as possible.  Bowel obstructions *ARE LIFE THREATENING*.  If the obstruction is not removed, you could die!

If you go to the emergency room because you think you have a bowel obstruction, you can expect the doctor to:

• Ask you a variety of questions about the location and type of pain.
• Ask you a variety of questions about your medical history, especially in regards to bowel disease.
• Probe your abdomen with his hands and ask you to describe the pain/sensitivity you feel from the probing.
• Listen to your intestinal noises to determine whether the gut muscles are paralyzed (one of the symptoms of a bowel obstruction).
• If the doctor thinks a bowel obstruction is likely, they will order some imaging tests that may include drinking a barium milkshake as x-ray contrast, followed by taking x-ray images of your gut over a period of time; a CT Scan with oral and IV contrast, an MRI (much less likely), or an ultrasound (also less likely).

Treatment

If the hospital admits you with a suspected bowel obstruction, the treatment consists solely of denying you anything to eat and treating your pain with pain medication.  If your body does not clear the bowel obstruction on its own, the doctors will intervene with surgery.  Nonspontaneous clearing of a bowel obstruction (your body clearing the obstruction) results in either starvation from not eating (to prevent further pressure on the blockage, which results in death) or a burst bowel (which results in death if not treated). My body has always cleared the bowel obstruction without requiring surgical intervention.

For me this treatment lasted as long as I display symptoms of a bowel obstruction.  My small bowel obstruction episodes have lasted from a few hours to 5 days (the longest so far).  A typical episode for me lasts 1-2 days.  During this time, I treat myself with pain medications as needed (do not use NSAIDS), anti-cramping medications as needed (Bentyl and Levsin), only consuming liquids, and reducing my physical activity to minimum essentials.

By now you may be wondering how I know that my body has cleared the obstruction.  Usually my body clears the obstruction through a combination of violent vomiting and diarrhea.  The process can take several hours requiring many bouts of both diarrhea and vomiting.  Sometimes I only experience vomiting and sometimes I only experience diarrhea.  Lately I have experienced much milder symptoms of blockage and a much more gentle process of clearing the blockage.  It still always results in vomiting, diarrhea, or both but the process has not been quite as violent.  I do not know why.

Diet

After I am certain that I cleared my blockage, I resume eating but I adopt a diet called “low residue.”  If you think you have experienced an intestinal blockage, speak to your doctor about the episode.  He will most likely want you to check yourself into the hospital the next time the symptoms arise (they will want confirmation about exactly what is happening).  If they do confirm that you are experiencing partial bowel obstructions, then your doctor will need to discuss treatment plans (so that they stop happening), what to do for the next one, and a change in your diet.

For years, my diet has excluded anything that has high fiber (avoiding fruits, vegetables, nuts, whole grains, etc.) and trying to eat things like eggs, cream of wheat, milk, and coffee.  After a couple of days I do start adding these things back into my diet but I do so gradually and begin with things like V8 juice, prune juice, applesauce, and other foods in which the fiber has been pureed.  In fact, I am attempting to increase my fiber intake while reducing my chances of experiencing more bowel obstructions by adding those items to my regular diet.

Foods that I know have caused my small bowel obstructions include:

• Vegetable heavy oriental stir-fry
• Oranges
• Popcorn
• Coconut
• Carrots
• Celery
• Onions
• Vegetable heavy pizza
• Any raw fruit or vegetable with a lot of fiber

When I do eat these foods now, I attempt to chew them thoroughly.  On advice of my GI (gastroenterologist) I try to chew them 20 times before swallowing, this is not as easy as it sounds.

If you have strictures, even wearing tight fitting clothes around your waist can initiate a bowel obstruction.  So in addition to watching your diet, do not wear tight fitting clothes!

On a personal note, I rarely take sick days now for things like the cold or flu.  These bowel obstructions are the reason.  I never know when one will happen and I *have* to take sick leave when they strike.  I am simply in too much pain to do anything productive.  I try to save all of my leave (I have combined vacation and sick leave now) to cover the days I might require for one of these obstruction "episodes" that I experience.

Technical Stuff:

Medically speaking there is a difference between a "bowel obstruction" and a "partial bowel obstruction".  The main difference is that with a partial bowel obstruction your body may be able to pass gas and/or liquids through the stricture and it is possible that your body could clear it spontaneously.  For diagnostic purposes, it may only be possible to determine whether your obstruction was "partial" if your body clears it on its own.  From this technical medical diagnostic perspective all of my obstructions have been partial (I did eventually clear all of them on my own).

Online resources also state that if you are admitted for one of these (an obstruction or partial obstruction) you will be given an NG (naso-gastric) tube (which goes up your nose, down your throat, and into your stomach) to help eliminate gases in your stomach and help with pressure.  They also say that the hospital will insert and IV and perhaps a peripherally inserted central catheter (PICC) line (for providing you nutrition directly into your arteries).  The hospital does not permit an obstruction patient from taking anything by mouth.

I have been admitted perhaps six times for obstructions with a stay of 3-5 days each and have NEVER gotten the NG tube or PICC line for it (I have had an NG tube before but not for an obstruction).  I can state that I have always gotten the "nothing by mouth" policy until after my body can pass gas or liquids through the stricture.

NG tube

11/22/2014 - Since I originally wrote this blog, I have had two PICC lines inserted.  They were inserted so I could give myself hospital grade IV antibiotics at home rather than total parenteral nutrition (TPN).

My PICC line

Pushing saline flush through a PICC line