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Rajesh Shah, MD

Gastroenterologist

Q: My Crohn’s Disease onset occurred when I got pregnant in 2013. Since the diagnosis and treatments I've noticed my flares almost always coincide with my menstrual cycle. Whether small pains or complete bowl obstruction flares, trouble times are always just before or occurring with my bleeding. Is this just me or is this a known factor?

A: In general, women may experience gastrointestinal symptoms around the time of their menstrual cycle. Multiple studies have been done comparing patients with IBD to patients without IBD and all groups experienced an increase of gastrointestinal symptoms around the time of their menstrual cycle. Importantly, if you feel your symptoms are consistent with a flare, speak with your doctor to run additional tests (such as blood or stool tests) to confirm this. If confirmed, then you and your doctor can discuss modifying your therapy to account for inflammation. Consider reviewing the Crohn’s and Colitis Foundation Women and IBD Fact Sheet for additional information (https://www.crohnscolitisfoundation.org/assets/pdfs/womenfactsheet.pdf). hide answer

Q: I have had resolving ulcerative colitis for several years; It is kept in check mostly through Asacol, then Lialda, and now generic mesalamine. Since switching to the generic, I have had very frequent burping, at times almost constantly. I have tried taking the medicine at a different time and with a full meal, and nothing seems to help. I know this is minor considering what some people deal with, but is there anything I can do to help with the burping?

A: Increased belching has been reported with oral mesalamine usage, so your symptoms may be related to the medication. However, if you are clinically doing well with this, then I would not recommend stopping your medications. You may consider speaking with your doctor about taking another formulation, if you did better with those. In general, excessive belching can be caused either by an increased swallowing of air with eating and drinking or may be related to underlying reflux. I would recommend seeing your gastroenterologist, who will likely take a careful history to help determine the etiology for your symptoms. Unless specific symptoms are present, you will not likely need further invasive testing, such as an endoscopy. In terms of management, this is guided by the reason for the symptoms, which may include behavioral changes (related to swallowing air), discontinuation of specific foods (for example, carbonated drinks and chewing gum) or if reflux is suspected medications directed at this. Consider reviewing the Crohn’s and Colitis Foundation Mesalamine Fact Sheet for additional information (https://www.crohnscolitisfoundation.org/assets/pdfs/aminosalicylates.pdf). hide answer

Q: I have been using Remicade treatment for 5 months. I have been getting skin ulcers, or boils since beginning use of this form of treatment. These not only look nasty but are very painful. This is my third skin issue. Is this a common side effect?

A: Remicade, though very effective for the treatment of IBD, has many potential side effects, including skin side effects. Up to approximately 10% of patients, may experience some form of skin related side effects, including rashes and itching. Of the skin related issues, development of psoriasis appears to be the most common. In your case, I would recommend promptly speaking with your gastroenterologist and possibly seeing a dermatologist for further care. In mild cases of psoriasis, the Remicade is continued and topical creams are used to control the skin related side effects. In more severe cases, Remicade (and related medications) are stopped and alternative therapies are used. hide answer

Q: I started Azathioprine 50 mg 2x daily about 30 days ago. Last week I started experiencing stomach bloating, gas, pain between my breast and then sharp pains on left side, radiating to my back and up to my shoulder. I stopped taking the pills, called doctor and visited about pancreatitis symptoms. Is this a side effect? Should I try again? I am on Remicade every 8 weeks and the inflammation continues.

A: With azathioprine, pancreatitis is a rare, but reported side effect. This does not appear to be related to the dose of the medication, but instead an idiosyncratic occurrence. If pancreatitis was confirmed, I typically do not resume azathioprine (or 6-mercaptopurine), as the patient may have recurrent episodes. Alternatively, a growing body of studies suggests monotherapy with Remicade (and other biologic therapies) dosed adequately is as effective as combination therapy (Remicade and azathioprine). Therefore, in patients unable to take azathioprine, I typically would recommend monotherapy with a biologic, such as Remicade, and checking the drug concentration to guide dosing. hide answer

Q: I recently started Entyvio and realize that it will take a while for it to kick in. In the meantime, my doctor's office suggested Metamucil to help add bulk to my stool which is currently just liquid. I have always been careful to avoid too much fiber and I am concerned that the Metamucil will cause more diarrhea and not less.

A: Fiber, or said another way, dietary fiber is actually composed of 2 types of fiber, soluble and insoluble fiber. Soluble fiber, such as the psyllium found in Metamucil, dissolves completely in water and forms a gel like consistency. When ingested, this helps add bulk to stool and soften stool, so it may be recommended for both diarrhea and constipation. Insoluble fiber, which is the type of fiber found with wheat and some fruits and veggies, does not dissolve well and also adds bulk to stool, but may also have a laxative effect. When adding additional fiber to the diet, start slowly at first (perhaps ½ tablespoon initially), as some supplements may cause bloating and abdominal pain, and then increase gradually as tolerated for the desired effect. For additional information related to fiber, consider reviewing the Crohn’s and Colitis Foundation Diet and Nutrition Handout (https://www.crohnscolitisfoundation.org/assets/pdfs/diet-nutrition-2013.pdf). hide answer

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