Ulcerative Colitis

Ulcerative colitis is a disease that causes inflammation and sores, or ulcerations, in the lining of the rectum and colon. Ulcerations form due to inflammation in the lining of the colon. Bleeding and pus in the colon result from the inflammation. Ulcerative colitis also causes the colon to empty frequently, causing diarrhea.

Illustration of the intestines. Source: NIDDK

Types

Ulcerative colitis usually does not affect the full thickness of the wall of the large intestine and hardly ever affects the small intestine. The disease usually begins in the rectum, or the rectum and the sigmoid colon (the lower end of the large intestine) but may eventually spread to part or all of the large intestine.

Ulcerative proctitis, which is confined to the rectum, is a very common and relatively benign form of ulcerative colitis. In some people, most of the large intestine is affected early on. If the entire colon is affected it is called pancolitis. If only the left side of the colon is affected it is called limited, or distal, colitis.

Ulcerative colitis is classified as an inflammatory bowel disease (IBD), the general name for diseases that cause inflammation in the small intestine and colon. Another form of IBD is Crohn's Disease. Crohn's disease differs from ulcerative colitis in that it causes inflammation deeper within the intestinal wall. Crohn's disease can also occur in other parts of the digestive system, including the small intestine, mouth, esophagus, and stomach.

Symptoms

Ulcerative colitis symptoms usually occur in flare-ups. A flare-up is when the rectum and/or colon become inflamed. During a flare-up, people experience periods of increased ulcerative colitis symptoms, such as bloody diarrhea, rectal bleeding, abdominal pain or cramping, and an urgent need to go to the bathroom. Flare-ups can vary in duration and intensity.

Patients may also experience:

• Anemia
• Loss of appetite
• Weight loss
• Fatigue
• Rectal bleeding
• Loss of body fluids and nutrients (which can lead to malnutrition)
• Skin lesions
• Joint pain
• Growth failure (specifically in children)

About half of the people diagnosed with ulcerative colitis have mild symptoms. Others suffer frequent fevers, bloody diarrhea, nausea, and severe abdominal cramps. Ulcerative colitis may also cause problems such as arthritis, inflammation of the eye, liver disease, and osteoporosis. It is not known why these problems occur outside the colon. Scientists think these complications may be the result of inflammation triggered by the immune system. Some of these problems go away when the colitis is treated.

Video Discussing Ulcerative Colitis

Causes

The cause of ulcerative colitis is unknown, but heredity and an overactive immune response in the intestine seem to be contributing factors. In contrast to Crohn's disease, smoking does not increase the risk of ulcerative colitis.

People with ulcerative colitis have abnormalities of the immune system, but it is not clear if these abnormalities are a cause or a result of the disease. In ulcerative colitis, the body's immune system does not react normally to the bacteria in the digestive tract.

Ulcerative colitis is not caused by emotional distress or sensitivity to certain foods or food products, but these factors may trigger symptoms in some people. The stress of living with ulcerative colitis may also contribute to worsening of symptoms.^[1]

Diagnosis

A physical exam and medical history are usually the first step in diagnosing ulcerative colitis.

Blood tests may be done to check for anemia, which could indicate bleeding in the colon or rectum. These tests may also uncover a high white blood cell count, which is a sign of inflammation somewhere in the body.

A stool sample can also reveal white blood cells, whose presence indicates inflammatory disease. In addition, a stool sample allows the doctor to detect bleeding or infection in the colon or rectum caused by bacteria, a virus, or parasites.

A colonoscopy or sigmoidoscopy are the most accurate methods for making a diagnosis of ulcerative colitis and ruling out other possible conditions, such as Crohn's disease, diverticular disease, or cancer. For both tests, the doctor inserts an endoscope (a long, flexible, lighted tube connected to a computer and TV monitor) into the anus to see the inside of the colon and rectum. With this equipment, the doctor will be able to see any inflammation, bleeding, or ulcers on the colon wall. During the exam, the doctor may do a biopsy, which involves taking a sample of tissue from the lining of the colon to view under a microscope.^[2]

Sometimes x rays done after a person has received a barium enema, or CT scans are also used to diagnose ulcerative colitis or its complications.

Treatment

Currently there is no cure though the different treatments can relieve and prevent symptoms, and even bring about remission of the disease. Treatment for ulcerative colitis depends on the severity of the disease. Each person experiences ulcerative colitis differently, so treatment is adjusted for each individual.

Drug Therapy

The goal of drug therapy is to induce and maintain remission, and to improve the quality of life for people with ulcerative colitis. Several types of drugs are available.

• Aminosalicylates, drugs that contain 5-aminosalicyclic acid (5-ASA), help control inflammation. Sulfasalazine is a combination of sulfapyridine and 5-ASA. The sulfapyridine component carries the anti-inflammatory 5-ASA to the intestine. However, sulfapyridine may lead to side effects such as nausea, vomiting, heartburn, diarrhea, and headache. Other 5-ASA agents, such as olsalazine, mesalamine, and balsalazide, have a different carrier, fewer side effects, and may be used by people who cannot take sulfasalazine. 5-ASAs are given orally, through an enema, or in a suppository, depending on the location of the inflammation in the colon. Most people with mild or moderate ulcerative colitis are treated with this group of drugs first. This class of drugs is also used in cases of relapse.^[1]
• Corticosteroids such as prednisone, methylprednisone, and hydrocortisone also reduce inflammation. They may be used by people who have moderate to severe ulcerative colitis, or who do not respond to 5-ASA drugs. Corticosteroids, also known as steroids, can be given orally, intravenously, through an enema, or in a suppository, depending on the location of the inflammation. These drugs can cause side effects such as weight gain, diabetes, acne, increased facial hair, hypertension, mood swings, loss of bone mass, and an increased risk of infection. For this reason, corticosteroids are not recommended for long-term use, although they are considered very effective when prescribed short-term.
• Immunomodulators such as azathioprine and 6-mercapto-purine (6-MP) reduce inflammation by affecting the immune system. These drugs are used for patients who have not responded to 5-ASAs or corticosteroids, or who are dependent on corticosteroids. Immunomodulators are administered orally. They are slow-acting and it may take up to 6 months for the full benefit to be achieved. Patients taking these drugs are monitored for complications including pancreatitis, hepatitis, a reduced white blood cell count, and an increased risk of infection. Cyclosporine A may be used with 6-MP or azathioprine to treat active, severe ulcerative colitis in people who do not respond to intravenous corticosteroids.

Other drugs may be given to relax a person during an exacerbation, or to relieve pain, diarrhea, or infection.

Some people will go into remission (periods when the symptoms go away), that last for months or even years. However, most patients' symptoms eventually return.

Hospitalization

Occasionally, symptoms are severe enough that a person needs to be hospitalized. For example, a person may have severe bleeding or severe diarrhea that causes dehydration. In such cases the doctor will try to stop diarrhea and loss of blood, fluids, and electrolytes. In severe cases, the person may need a special diet. If the person is unable to eat, he or she may need to be fed through a vein. Intravenous medications are sometimes given to treat infections that can occur during flare-ups. Surgery is usually used only when other treatments have ceased to provide adequate relief.

Surgery

About 25 to 40 percent of ulcerative colitis patients must eventually have their colons removed because of massive bleeding, severe illness, rupture of the colon, or risk of cancer. Sometimes the doctor will recommend removing the colon if medical treatment fails or if the side effects of corticosteroids or other drugs threaten the patient's health.

Surgery to remove the colon and rectum, known as proctocolectomy, is followed by one of the following:

• Ileostomy, in which the surgeon creates a small opening in the abdomen, called a stoma, and attaches the end of the small intestine, called the ileum, to it. Waste then travels through the small intestine and exits the body through the stoma. The stoma is about the size of a quarter and is usually located in the lower right part of the abdomen near the beltline. A pouch is worn over the opening to collect waste. The patient empties the pouch as needed.
• Ileoanal anastomosis, or pull-through operation, which allows the patient to continue to have normal bowel movements because it preserves part of the anus. In this operation, the surgeon removes the colon and the inside of the rectum, leaving the outer muscles of the rectum. The surgeon then attaches the ileum to the inside of the rectum and the anus, creating a pouch. Waste is stored in the pouch and passes through the anus in the usual manner. Bowel movements may be more frequent and watery than before the procedure. Inflammation of the pouch (pouchitis) is a possible complication.

Not every operation is appropriate for every person. Which surgery to have depends on the severity of the disease and the patient's needs, expectations, and lifestyle. People faced with this decision need as much information as possible, which they can obtain by talking to their doctors, to nurses who work with colon surgery patients (enterostomal therapists), and to other colon surgery patients. Patient advocacy organizations can direct people to support groups and other information resources.

Living with Ulcerative Colitis

Living with ulcerative colitis involves learning how to manage the condition. It is important to:

• Take all prescribed medication
• Eat a balanced, nutritionally sound diet
• Get and stay informed on this condition
• Use family, friends, support groups to help with emotional support

People all over the country attend support groups to help cope with ulcerative colitis. One organization is the Crohn's & Colitis Foundation of America (CCFA). Topics of discussion include:

• Reactions to having a chronic illness
• Reactions of friends and family
• Impact of Inflammatory Bowel Disease on lifestyle
• Talking with your doctor
• Feelings about medical treatment
• Feelings about sex
• Sharing coping strategies

Lifestyle changes

In addition to making dietary changes and taking medicine, there are a few lifestyle changes that may be helpful in dealing with ulcerative colitis. Lifestyle changes that can help deal with ulcerative colitis can include:

• Reducing stress
• Counseling or support.

Although stress doesn't cause ulcerative colitis, it can make the symptoms worse. Many events, including family problems or the death of a loved one, can cause obvious stress. However, everyday events like getting stuck in traffic can also cause stress. Although the connection between stress and ulcerative colitis isn't well-understood, learning to deal more effectively with stress may help relieve the symptoms.

Some of the ways to try to reduce stress include:

• Biofeedback, which teaches you to use your thoughts to control things like muscle tension and heart rate
• Regular exercise
• Yoga
• Getting regular massages
• Deep breathing techniques
• Meditation
• Setting aside time to do the things you enjoy.

Ulcerative Colitis Diet Changes

Ulcerative colitis research has shown that there is no diet that can prevent or cure the condition. However, many people find that certain types of foods can worsen their symptoms.

Dietary changes that have been shown to be helpful in ulcerative colitis are^[3]

• Limiting dairy products
• Increasing low-fat foods
• Varying the amount of protein and fiber you eat
• Avoid problem, "gassy" foods
• Eat more frequent, smaller meals

Chances of Developing Ulcerative Colitis

Ulcerative colitis can occur in people of any age. However, it usually starts between the ages of 15 and 30, and less frequently between 50 and 70 years of age. Ulcerative colitis affects men and women equally and appears to run in families. Up to 20 percent of people with ulcerative colitis have a family member or relative with ulcerative colitis or Crohn's disease. A higher incidence of ulcerative colitis is seen in caucasians and people of Jewish descent.

Related Problems

Complications

About 5 percent of people with ulcerative colitis develop colon cancer. The risk of cancer increases with the duration of the disease and how much the colon has been damaged. For example, if only the lower colon and rectum are involved, the risk of cancer is no higher than normal. However, if the entire colon is involved, the risk of cancer may be as much as 32 times the normal rate.

Sometimes precancerous changes occur in the cells lining the colon. These changes are called "dysplasia". People who have dysplasia are more likely to develop cancer than those who do not. Doctors look for signs of dysplasia when doing a colonoscopy or sigmoidoscopy, and when examining tissue removed during these tests.

According to the 2002 updated guidelines for colon cancer screening, people who have had IBD throughout their colon for at least 8 years, and those who have had IBD in only the left colon for 12 to 15 years should have a colonoscopy with biopsies every 1 to 2 years to check for dysplasia. Such screening has not been proven to reduce the risk of colon cancer, but it may help identify cancer early. These guidelines were produced by an independent expert panel and endorsed by numerous organizations, including the American Cancer Society, the American College of Gastroenterology, the American Society of Colon and Rectal Surgeons, and the Crohn's & Colitis Foundation of America.

Other complications can occur, as in Crohn's disease. When ulcerative colitis causes a flare-up of gastrointestinal symptoms, the person also may experience inflammation of the joints (arthritis), inflammation of the whites of the eyes (episcleritis), inflamed skin nodules (erythema nodosum), and blue-red skin sores containing pus (pyoderma gangrenosum). When ulcerative colitis is not causing a flare-up of gastrointestinal symptoms, the person still may experience pyoderma gangrenosum. Inflammation of the spine (ankylosing spondylitis), inflammation of the pelvic joints (sacroiliitis), and inflammation of the inside of the eye (uveitis) can occur entirely without relation to the bowel disease. Rarely, blood clots develop in the veins.

Although people with ulcerative colitis commonly have minor liver dysfunction, only about 1 to 3% have symptoms of mild to severe liver disease. Severe liver disease can include inflammation of the liver (chronic active hepatitis); inflammation of the bile ducts (primary sclerosing cholangitis), which narrow and eventually close; and replacement of functional liver tissue with scar tissue (cirrhosis). Inflammation of the bile ducts may appear many years before any intestinal symptoms of ulcerative colitis. The inflammation greatly increases the risk of cancer of the bile ducts and also seems to be associated with a sharp increase in the risk of colon cancer.

References

1. ↑ ^{1.0 1.1} Shih DQ, Targan SR. Immunopathogenesis of inflammatory bowel disease. World J Gastroenterol. 2008 Jan 21;14(3):390-400. Abstract | Full Text
2. ↑ Ando T, Nishio Y, Watanabe O, Takahashi H, Maeda O, Ishiguro K, et al. Value of colonoscopy for prediction of prognosis in patients with ulcerative colitis. World J Gastroenterol. 2008 Apr 14;14(14):2133-8. Abstract | Full Text
3. ↑ Shah S. Dietary factors in the modulation of inflammatory bowel disease activity. Med Gen Med. 2007 Mar 27;9(1):60. Abstract | Full Text

External Links

Crohn's and Colitis Foundation of America: Ulcerative colitis and Proctitis

Crohn's and Colitis Foundation of Canada

National Association for Colitis and Crohn's Disease [1]

Free Presentations of the 4th Congress of ECCO - the European Crohn`s and Colitis Organization: [2]