Chronic Pancreatitis: Advice to Help with Constipation

Nutrition Interest Group of the Pancreatic Society (NIGPS)

Chronic Pancreatitis: Advice to help with constipation

Contents

What is constipation? ...... 2 What are the symptoms of constipation? ...... 2 How are stools formed? ...... 2 What can cause constipation? ...... 3 How can you change your diet and lifestyle to help prevent and treat constipation? ...... 4 Are there any medications that can affect constipation? ...... 6 When to ask for help? ...... 6

Chronic Pancreatitis: Advice to help with constipation © NIGPS 2018 1

Nutrition Interest Group of the Pancreatic Society (NIGPS)

What is constipation?

Constipation refers to bowel movements that are infrequent and/or difficult to pass.

What are the symptoms of constipation?

Symptoms of constipation can vary from one person to another, but can include:

• Difficulty and pain when having a bowel movement

• Having to strain a lot when trying to open your bowels

• Fewer than 3 bowel movements a week

• Small hard pellet like stools

• Feeling bloated

• Crampy type abdominal pain, relieved by having your bowels open

• Very loose watery stool mixed in with small pellets (this is called ‘overflow diarrhoea’)

Over time you may feel nauseous, vomit, have stomach pain, headaches, reduced appetite, and you may feel tired or lethargic.

How are stools formed?

Food is digested (broken down) inside your gut. Once broken down, the water and nutrients from your food are drawn from the gut into your body. Stools (or faeces) are a combination of waste products from food digestion and dead cells, mucous etc. from your gut.

Muscle contractions in your gut push the stools towards your rectum (back passage) where they are stored until you are ready to open your bowels.

Chronic Pancreatitis: Advice to help with constipation © NIGPS 2018 2

Nutrition Interest Group of the Pancreatic Society (NIGPS)

What can cause constipation?

Constipation may occur if:

1) Too much water is absorbed by the gut, making the stool hard, dry and difficult to pass (when the stool stay in the gut for too long)

2) Muscle contractions in the gut are too slow or weak, causing the stool to move very slowly. The stools may stay in the same place for hours or days, meaning more water is absorbed and they become hard and dry.

There are a number of factors that can contribute to becoming constipated. These include:

• Side effects of medications including:

 Opiate based painkillers (such as codeine and morphine)

 Some anti-sickness drugs (such as ondansetron)

 Iron supplements

• Not eating enough fibre

• Not drinking enough fluids

• A change in your meal patterns

• Lack of physical activity

• Ignoring the urge to pass stools

• Long term use of laxatives

• Being underweight or overweight

• Anxiety and depression

• Other medical conditions such as irritable bowel syndrome or diverticular disease

• Consequence of an illness or surgery

Chronic Pancreatitis: Advice to help with constipation © NIGPS 2018 3

Nutrition Interest Group of the Pancreatic Society (NIGPS) How can you change your diet and lifestyle to help prevent and treat constipation?

 Eat at regular times each day

o Avoid skipping meals or eating irregularly as this can decrease bowel function and cause constipation. If you are missing meals because of pain or a poor appetite, speak to your Dietitian.

 Include fibre in your diet

o Fibre is the part of plant foods that passes through your gut undigested. This provides bulk to your stools and can help to prevent constipation.

o You can increase your fibre intake by eating:

 Plenty of fruit and vegetables (aim for at least five portions a day)

 More beans, pulses, lentils and oats

 Wholegrain cereal

 Wholemeal or granary bread instead of white bread

 Wholegrains such as wholewheat pasta or brown rice rather than

the white variety

 Linseeds added to yogurt, cereal or soup

(up to 1 tablespoon a day)

 It is important to slowly increase the amount of fibre in your diet, to help your gut to adapt. Making too many changes all at once may cause some people to suffer from wind and bloating. Be aware that very large amounts of fibre can cause diarrhea, which can reduce absorption of nutrients.

 A very high fibre diet may reduce the effectiveness of pancreatic enzymes. If you take enzyme replacement medications (such as Creon/Nutrizym/Pancrease) and these are not working optimally, you may be advised to lower your fibre intake and use some of the other tips discussed in this booklet to aid your bowel function.

Chronic Pancreatitis: Advice to help with constipation © NIGPS 2018 4

Nutrition Interest Group of the Pancreatic Society (NIGPS)

 Drink plenty of fluid

o It’s very important that you drink enough fluid, especially if you are increasing your fibre intake. This will ensure that your stools remain soft and easy to pass. Try to drink at least 8-10 glasses of fluid a day (more when exercising or if the weather is hot).

o Be aware that alcohol and drinks containing caffeine such as cola and coffee can cause dehydration, so limit these. A sign of being well hydrated is passing pale, straw-coloured urine.

 Be as active as possible

o Regular exercise helps to keep your bowel movements regular. Symptoms of chronic pancreatitis such as pain and lethargy can make it difficult to exercise. But a little exercise is better than none. A short walk each day may make all the difference to keeping your bowel motions soft and regular.

 Try prunes and prune juice, or stewed fruit such as pears or apples

 Do not ignore the urge to have a bowel movement

o Giving yourself enough time and privacy to pass stools comfortably may help and you should not ignore or delay the urge to go to the toilet.

 Try placing your feet on a low stool or thick book while going to the toilet, so that your knees are above your hips. Some people find bringing their knees up to their chin before a bowel movement can help.

 If you feel anxious or depressed, discuss this with your GP, nurse or hospital doctor. There is help available to support you with this.

Chronic Pancreatitis: Advice to help with constipation © NIGPS 2018 5

Nutrition Interest Group of the Pancreatic Society (NIGPS)

Are there any medications that can affect constipation?

 Some medications can cause constipation

o Some medications may be essential whilst others could be adjusted. If you are constipated, discuss your medications with your doctor to see if alternatives can be tried.

 Laxatives might well be necessary

o If you have explored the above options and remain constipated, ask your doctor about taking a laxative. There are different types that work in different ways to either soften the stool or help them to move through the gut faster.

o If you need to take an opiate based painkiller on a long term basis, you may be prescribed laxatives to help relieve constipation occurring as a side effect.

 Ensure adequate pancreatic enzymes

o Remember that people who are taking opiate based painkillers tend to become constipated. If you are taking an opiate based painkiller such as morphine and are not constipated, you might not be digesting your food fully and may need to start or increase your dose of pancreatic enzyme supplements (such as Creon®, Nutrizym®, Pancrex® or Pancrease HL®). If this is the case discuss it with your doctor, dietitian or specialist nurse.

o Do not be tempted to reduce your dose of enzymes to treat constipation. This will lead to you not digesting your food adequately, and could cause malnutrition. It is better to take the right amount of enzymes alongside a laxative, if needed.

When to ask for help?

The diet, lifestyle and medication advice discussed in this information sheet should help to prevent or relieve constipation. However, if your constipation is not getting any better, it is important to let your doctor or nurse know. The earlier you tell them, the easier it will be to treat and the more comfortable you will be

Nutrition Interest Group of the Pancreatic Society (NIGPS)

The information in this booklet does not replace the advice given to you by your Dietitian/Doctor/Nurse Specialist.

The advice in this booklet is suitable for most people, but everyone is different.

The contents of this booklet may differ to the information given to you by your medical team as their advice is specific to you, and your condition.

Other leaflets available in this series with more information on specific areas are:

• Pancreatic enzyme replacement therapy • Type 3c diabetes (pancreaticogenic diabetes) • Pancreatic disease and physical activity • Nutrition and acute pancreatitis • Chronic pancreatitis and your diet • Chronic pancreatitis: high energy, high protein advice.

Useful contacts:

Pancreatitis supporters network : www.pancreatitis.org.uk Pancreatitis Forum: www.pancreatitis-forum.org.uk Core: http://corecharity.org.uk/ www.nhs.org.uk Diabetes UK – 0345 1232399 www.diabetes.org.uk Alcohol concern - helpline (UK) 0300 1231110 www.alcoholconcern.org.uk Alcoholics Anonymous – helpline (UK) 0845 7697555 www.alcoholics- anonymous.org.uk Al-Anon Family groups – helpline (UK) 020 74030888 www.al-anonuk.org.uk Smoke free national helpline (UK) 0300 1231044

These websites are separate organisations, and the authors of this booklet have no control over their contents

Always be careful with information obtained from the internet, when carrying out internet searches try and stick to accredited sites.

Nutrition Interest Group of the Pancreatic Society (NIGPS) This booklet has been given to you by:

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Contact Number:......

Authors

Elizabeth Bradley Specialist Dietitian - Liver, HPB and NET, Queen Elizabeth Hospital Birmingham

Emily Button Specialist Gastro Surgical Dietitian, Addenbrooke’s Hospital, Cambridge

Deirdre Burke Senior Dietitian-Pancreatic Cancer Care, St. Vincent’s University Hospital, Dublin

Kate Latimer Hepato-Pancreatico-Biliary Specialist Dietitian, Sheffield

Laura Rettie Surgical Specialist Dietitian, Aberdeen Royal Infirmary

Peer reviewed by: Dr Sinead Duggan, Post Doctoral Research Fellow, Trinity College, Dublin Oonagh Griffin, Specialist Pancreatic Dietitian, PhD Candidate, Trinity College Dublin Kathryn Freeman, Hepato-Pancreatico-Biliary Specialist Dietitian, Sheffield Laura McGeeney, Pancreatic Specialist Dietitian, Addenbrooke’s Hospital, Cambridge Mary Phillips, Hepato-Pancreatico-biliary Specialist Dietitian, Guildford Sarah Dann, Hepato-Pancreatico-Biliary Specialist Dietitian, Royal Free Hospital, London Mr Asif Jah, Consultant HPB & Transplant Surgeon, Addenbrooke’s Hospital, Cambridge

Publication Date: December 2018, Review Date: December 2021