Ulcerative Colitis

Picture of a section of the bowel affected by ulcerative colitis.

• Ulcerative colitis (UC) is an acute or chronic inflammation of the membrane that lines the colon (the large intestine or large bowel). The inflammation occurs in the inner most layer of the colon and may result in the formation of sores (ulcers). Ulcerative colitis rarely affects the small intestine except for the lower most section, called the terminal ileum.
• The inflammation makes the colon empty frequently causing diarrhea. Ulcers form in places where the inflammation has killed the cells lining the colon. The ulcers bleed and produce pus and mucus.
• Symptoms of ulcerative colitis include abdominal pain, diarrhea, rectal bleeding, a recurrent urge to have a bowel movement (tenesmus), lack of appetite, fever, and fatigue.
• Abdominal pain, diarrhea, and bloody bowel movements are the hallmark of the disease. The disease initially causes inflammation in the rectum and may gradually spread to involve the whole colon. If just the rectum is involved, it is referred to as ulcerative proctitis.
• Ulcerative colitis is one of the inflammatory bowel diseases (IBD), the other is Crohn's disease.
  • Ulcerative colitis may be difficult to diagnose because its symptoms may mimic other intestinal disorders such as irritable bowel syndrome.
  • Crohn's disease differs from ulcerative colitis in several ways: it causes inflammation deeper within the intestinal wall, it may occur anywhere in the digestive tract, from the mouth to the anus, and is patchy in nature. While Crohn's disease most often occurs in the small intestine, there can be scattered lesions throughout the gastrointestinal tract. Ulcerative colitis affects only the colon and progresses proximally from the rectum in a continuous manner to potentially involve the rest of the colon.
  • There are an estimated 1-1.3 million people in the United States who suffer from inflammatory bowel disease. Ulcerative colitis is generally found in younger people and the diagnosis is often made in people between the ages of 15 and 30. Less frequently, the disease can also occur in people later in life, even past the age of 60. It affects both men and women equally, and there is a familial predisposition to its development. Those of Jewish heritage have a higher incidence of ulcerative colitis.

Common symptoms of ulcerative colitis include the following:

• Frequent loose bowel movements with or without blood
• The urgency to have a bowel movement (tenesmus) and bowel incontinence (loss of bowel control)
• Lower abdominal discomfort or cramps
• Fever, lethargy, and loss of appetite
• Weight loss with continuing diarrhea
• Anemia due to bleeding with bowel movements

Because inflammatory bowel disease may be caused by a defect in the immune response system, other body organs may be involved:

• Vision problems or eye pain
• Joint problems
• Neck or lower back pain
• Skin rashes
• Liver and bile duct disease
• Kidney problems

Tell a healthcare professional about any persistent changes in bowel habits. If the patient is already under treatment for inflammatory bowel disease or irritable bowel syndrome, contact a doctor if the patient experiences any prolonged changes in the symptoms or passes blood in the stools.

When Should You Call 911 or Go to the Emergency Department?

Seek medical care if any of these conditions are associated with colitis.

• Blood or mucus in your stool (Blood is never normal in a bowel movement. While it may be due to a relatively simple cause like hemorrhoids, it is important to make certain that the bleeding is not due to inflammatory bowel disease, tumor, or another potentially life-threatening cause.)
• Diarrhea that lasts more than three days.
• Severe abdominal or rectal pain
• Signs of dehydration such as dry mouth, excessive thirst, little or no urination
• Frequent loose bowel movements during pregnancy.
• Progressively looser bowel movements and appearance of other symptoms such as joint pain, vision changes, and increased weakness
• Diarrhea with fever.

Seek emergency medical attention if the following situations occur:

• Abdominal pain with fever.
• Bloody bowel movements.
• Severe abdominal pain even if you already have the diagnosis of inflammatory bowel disease
• Signs of dehydration.
• Progression or appearance of new symptoms over a few hours

The cause of ulcerative colitis is uncertain. Researchers believe that the body's immune system reacts to a virus or bacteria, causing ongoing inflammation in the intestinal wall. Although UC is considered to be a problem with the immune system, some researchers believe that the immune reaction may be the result, not the cause, of ulcerative colitis.

While ulcerative colitis is not caused by emotional stress or food sensitivities, these factors may trigger symptoms in some people.

Risk factors for inflammatory bowel disease include:

• Genetic or family history: There is a high similarity of symptoms among identical twins, particularly with Crohn's disease. A person has a greater risk of getting the disease if a first-degree relative such as a parent or a sibling is affected.
• Infectious agents or environmental toxins: No single agent has been associated consistently as a cause of inflammatory bowel disease. Viruses have been found in tissue samples from people with inflammatory bowel disease, but there is no incriminating evidence that these are the sole cause of the disease.
• Immune system: Several changes in the immune system have been identified as contributing to inflammatory bowel disease, but none are proven to specifically cause either ulcerative colitis or Crohn's disease.
• Smoking: Smokers increase their risk of developing Crohn's disease by twofold. In contrast, smokers have only one-half the risk of developing ulcerative colitis.
• Psychological factors: Emotional factors do not cause inflammatory bowel disease. However, psychological factors may modify the course of the disease. For example, stress may worsen symptoms or cause a relapse and may also affect the response to therapy.

A thorough physical exam and a series of tests may be required to diagnose ulcerative colitis.

Inflammatory bowel disease may mimic other conditions, and symptoms may vary widely. The correct diagnosis of ulcerative colitis may take some time. A health care professional will want to consider a variety of potential medical conditions and referral to a gastroenterologist may be required.

History: The doctor may ask the patient several questions to find out possible causes of the person's colitis. Answers to these questions will help assess the patient's condition, how to make the diagnosis and plan the treatment.

Physical exam: The doctor will examine the abdomen and other body systems. This will include performing a rectal examination to check for abnormal growths or masses and blood in the stool.

Laboratory tests: The doctor will decide which tests are needed based on the symptoms, medical history, and clinical findings. Some of the most commonly used tests are these:

• Stool samples to check for evidence of bleeding or infection.
• Complete blood count (CBC) to check for anemia or infection.
• Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) which may be abnormal in an acute flare of inflammatory bowel disease. These are non-specific tests that reflect presence of inflammation within the body.
• Electrolyte levels in the blood, especially looking for abnormalities in sodium and potassium levels, chemicals that can be lost from the body because of profuse diarrhea.
• Albumen levels, especially in severe inflammatory bowel disease, to assess protein loss from the inflamed intestine or impairment of liver function.
• Liver function tests

Imaging

Certain X-rays and other imaging tests will further pinpoint a diagnosis of colitis. The decision as to which test to use depends upon the patient's symptoms and presentation.

• Plain X-rays of the abdomen tend not to be helpful in the general evaluation of abdominal pain. In emergency situations, they may be done to look for bowel obstruction or abnormal locations of air due to a perforation of the bowel.
• Contrast X-rays with fluoroscopy may be helpful in the diagnosis. Upper GI series, small bowel studies, and enemas using barium or other liquids to outline the structures of the digestive tract, while a radiologist monitors the results in real time.
• Computerized tomography (CT) scans may be used to evaluate the digestive tract as well as other organs for a variety of diseases.

Procedures

The lining of the intestine may be viewed directly by a gastroenterologist using a thin flexible camera that is inserted through the anus and threaded up the colon, known as colonoscopy. Sigmoidoscopy allows the physician to see the lower portion of the colon, while colonoscopy allows visualization of the whole of the large intestine.

Aside from evaluating the lining of the colon, with colonoscopy or sigmoidoscopy, there is the opportunity to obtain biopsies, or small pieces of tissue for examination under a microscope. These biopsies may be helpful in confirming the diagnosis of ulcerative colitis or Crohn's disease.

Treatment for ulcerative colitis depends on the severity of the disease. Most people are treated with medication. If there are significant bleeding, infection, or complications, surgery may be required to remove the diseased colon. Surgery is the only cure for ulcerative colitis.

Ulcerative colitis may affect patients in different ways, and treatment is adjusted to meet the needs of the specific patient. Emotional and psychological support is also important.

The symptoms of ulcerative colitis come and go. Periods of remission, in which symptoms resolve, may last for months or years before relapsing. Patients and physicians need to decide together whether medications will be continued during remission times. In some patients, it may be the case that the medications keep the disease under control, and stopping them will cause a relapse.

Ulcerative colitis is a lifelong illness and cannot be ignored. Routine medical check-ups are necessary and scheduled colonoscopies are important to monitor the health of the patient and to make certain that the ulcerative colitis is under control and not spreading.

Complications

• Significant complications may occur with an acute flare of ulcerative colitis including dehydration, electrolyte abnormalities from profuse diarrhea, and anemia from rectal bleeding.
• A surgical emergency exists if the colon becomes weakened at a site of inflammation and perforates, spilling bowel contents into the abdominal cavity.
• Other organs of the body may become inflamed, including the eyes, muscles, joints, skin, and the liver.
• Primary sclerosing cholangitis may be associated with severe ulcerative colitis. In this condition the ducts that drain bile from the liver become inflamed and scared.

The risk of cancer

Colon cancer is the major long-term complication of ulcerative colitis. The risk of colon cancer is estimated to be 2% after 10 years, 8% after 20 years and 18% after 30 years of disease. The risk is greater for those whose entire colon is affected as opposed to those who have only a small segment involved such as the rectum. Screening colonoscopy is recommended 8 to 10 years after the onset of the initial symptoms to look for cancer or pre-cancerous changes in the lining of the colon. Colonoscopy should be repeated routinely, the frequency depends upon whether a part or all of the colon is involved with the disease and how long the disease has been present.

Associated illnesses

• Primary sclerosing cholangitis may be associated with severe ulcerative colitis. In this condition the ducts that drain bile from the liver become inflamed and scarred.
• Iritis or uveitis. These diseases indicate inflammation of the eye.
• Ankylosing spondylitis, a disease that causes inflammation in the joints between the vertebrae in the spine and the joints between the spine and the pelvis.
• Erythema nodusum, in which the skin becomes inflamed.

Proper nutrition is important for a person with ulcerative colitis. Foods do not cause ulcerative colitis, but certain food groups can cause symptoms to flare. Often it is a process of trial and error to find what foods need to be avoided. Although specific foods do not cause the disease, some types of food may trigger discomfort and diarrhea. Keep a food diary to help find foods that cause problems.

• Dairy foods. Some patients with ulcerative colitis may also have lactose intolerance that can make the diarrhea worse.
• High fiber is often recommended to aid with bowel regularity, but may make the diarrhea worse in ulcerative colitis. Whole grains, vegetables, and fruit may worsen pain, gas, and diarrhea. Finding foods that are the culprit may require a trial and error approach.
• Gassy foods (flatulence). Mild diarrhea may be controlled with diet, and by trial and error, you may find other "gassy" foods like caffeine and carbonated beverages.
• Spicy foods may need to be eliminated especially when the diarrhea phase is active.
• Grazing. Small, frequent meals may be helpful in controlling symptoms. Grazing during the day may be better than 2 or 3 large meals.
• Avoid dehydration. The body can lose a significant amount of water with diarrhea, and drinking plenty of fluids to replace that loss is very important. Increase in fluid intake is encouraged to prevent dehydration. Urine output can be used as a gauge of hydration. If the urine is yellow and concentrated, more fluid may be required.
• Vitamins and supplements. A less than rounded diet may require vitamin and mineral supplements, and visiting with a dietician is often an important step in maintaining good nutrition while controlling the symptoms.

Counseling and education are important for both the patient and family; a better understanding of how ulcerative colitis affects the body will allow the patient and physician to work together to control the symptoms.

The patient's health care professional will consider the possible causes of colitis, and any complications that need urgent treatment. The treatment goal of active ulcerative colitis is to relieve the inflammation and replace nutritional losses and loss of fluid due to diarrhea. Most people improve with this approach.

• Drugs to control mild diarrhea, for example, diphenoxylate (Lofene, Lomotil), loperamide (Imodium, Kaopectate), codeine, and anticholinergics (Anaspaz, Cystospaz, Bentyl) may help to reduce the number of bowel movements and relieve the feeling of bowel urgency. However, you should avoid these drugs if you have severe diarrhea because of inflammatory bowel disease. They should not be used if a fever is present.
• Cholestyramine (Questran), an agent that binds bile salts, helps to control diarrhea associated with Crohn's disease, particularly in people who have had a portion of their small intestine removed. Dicyclomine (Bentyl) may relieve intestinal spasms.
• Severe attacks of inflammatory bowel disease require hospital admission and supportive care including bowel rest, IV fluids, and correction of any electrolyte imbalance.
• Restricted diet. The patient will likely be given a restricted diet.

Medications that are used in the treatment of ulcerative colitis may be divided into two groups, anti-inflammatory and immune suppressive agents. The decision as to which medication regimen should be used will depend upon the severity of the ulcerative colitis. Physicians and patients need to discuss the benefits and risks of recommended treatments.

If the patient has mild or moderate colitis, the first line of treatment is the use of 5-ASA agents-a combination of two drugs sulfonamide (sulfapyridine) and salicylate that helps to control the inflammation. Sulfasalazine (Azulfidine) is the most commonly used of these drugs. Sulfasalazine can be used for as long as needed and can be given along with other drugs. If the patient does not do well on sulfasalazine, they may respond to the newer 5-ASA agents. The side effects of 5-ASA preparations include nausea, vomiting, heartburn, diarrhea, and headache.

Drug therapy for active inflammatory bowel disease includes the following:

• Mesalamine-derivatives (Asacol, Pentasa, Lialda, Delzicol): These are used for Crohn's colitis and ulcerative colitis.
• Antibiotics: Clotrimazole (Lotrimin) and ciprofloxacin (Cipro, Ciloxan) are prescribed for Crohn's disease of the rectum and anus.
• Predigested (elemental or polymeric) diet for small bowel Crohn's disease

If the patient has severe colitis or does not respond to mesalamine preparations, they may be treated with corticosteroids. Prednisone (Deltasone, Orasone, Prednicen-M, Liquid Prep), methylprednisolone (Medrol, Depo-Medrol), budesonide (Entocort EC), budesonide MMX (Uceris) and are used to reduce inflammation. These drugs are taken during a flare-up, but are not used for maintenance when the ulcerative colitis is in remission. Corticosteroids can be taken by mouth, IV infusion, through an enema, or as a suppository, depending upon the location and severity of the inflammation.

Long term use of corticosteroids (may cause side effects including weight gain, acne, facial hair, high blood pressure, mood swings, and increased risk of infection.

A doctor will monitor the patient closely while taking these drugs. The idea is to take corticosteroids only for flare-ups for a short period of time. They do not stop the condition from coming back.

If the patient responds only partially to these treatments or has early relapse, the doctor may consider aggressive therapy. Aggressive therapy may include the following steps:

• Hospital admission
• IV steroids instead of oral steroids
• Increasing the steroid dose
• Use of antibiotics (imidazole or ciprofloxacin or both) for Crohn's disease of the rectum and anus

Suppressing the immune system may help to control the symptoms of ulcerative colitis in patients who have failed first line drug treatment or whose disease is advanced. Medications used for this purpose include:

• Azathioprine (Azasan, Imuran) and mercaptopurine (Purinethol)
• Cyclosporine (Gengraf, Neoral, Sandimmune
• Infliximab (Remicade)
• Adalimumab (Humira)
• Golimumab (Simponi)

These medications have significant side effects and need close monitoring. The decision to use them as part of the treatment regimen often requires long discussion between patient and doctor.

If these aggressive measures do not work, surgery may be an option to remove the colon.

Most people with ulcerative colitis will never need to have surgery. However, if surgery becomes necessary, the operation permanently cures ulcerative colitis since the disease only affects the colon and not other parts of the intestinal tract.

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. For the 23% to 45% of people who eventually may have their colons removed because of massive bleeding, severe illness, rupture of the colon, or risk of cancer, various surgical techniques are used. The choice of surgical procedure is individualized based upon the needs of each patient. What is right for one patient may not be the best type of surgery for someone else.

• The most common surgery is a proctocolectomy with ileostomy, where the surgeon removes the whole colon, including the rectum. An ileoanal anastomosis or pull-through operation then connects the small intestine to the anus. This operation does not require a stoma, where the small intestine is pulled through the abdominal wall and empties into a pouch that is attached to the outside of the abdomen.
• The decision to perform the pull-through operation as opposed to making a stoma depends upon the patient's situation.
• An ileoanal anastomosis has the advantage that the patient does not pass the stools into a pouch or a bag. However, the bowel movements tend to be more frequent and watery since there is no colon to reabsorb water from the stools.

Lifestyle modifications

• If the patient has been on steroids for a long time, the person may have some added risk because this medication reduces the bone mass.
• High-impact exercise such as aerobics or running may put too much stress on the fragile bones causing stress fractures or broken bones.
• Low-impact exercises may be more appropriate, such as cycling or swimming.
• A bone density screening arranged through a doctor can look at bone mass and assess if the patient is at risk.
• Strength training (resistance activity) with moderate weights or machines, even stretch bands, may help build bone density.

Traveling with ulcerative colitis can be a challenge if the patient feels the need to use the bathroom frequently. Sometimes you simply "can't wait," so experts have some prudent suggestions:

• Public toilets. Become aware of public toilets where you are traveling and plan your day's activities so you have a comfort level (and another adult to watch the children) in being close to a toilet facility.
• Medical condition card. Carry a card that says I can't wait and explains that you have a medical condition in which you urgently need to use the bathroom. If you encounter a long line and are desperate, hand the card to the first person in line.
• Familiar roadside toilet facilities. Look for familiar and usually clean roadside toilet facilities such as at fast-food places.
• Airplane travel presents its own challenges. If you're not traveling first class, know that the toilet facilities up front are usually not as crowded as those in coach class. Explain your concerns to the flight attendants when you board: "I probably won't have to use the facilities up front, but in case I do, I have a medical condition, and I can't wait in line."
• Anxiety. If trip anxiety makes you even more anxious about accidents, do wear an adult diaper. Women may opt for a maxipad or panty shield. Pack and bring an extra change of underwear and pants in your carry-on and keep them with you in a day-pack while sightseeing.
• Unfamiliar foods. Some foods may be unfamiliar and their effects uncertain. Know what foods you are eating. Buy familiar items at local grocery stores and carry them with you on tours if you're just not sure you want to tackle the native cuisine or worry that it may trigger your condition.

Some patients will try alternative medicines to help treat ulcerative colitis. There is no evidence, as yet, that probiotics, fish oil, spices, and acupuncture are beneficial.

• Ulcerative colitis is not a fatal illness, but it is a lifelong illness.
• Most people with ulcerative colitis continue to lead normal, useful, and productive lives, even though they may need to take medications every day, and occasionally need to be hospitalized.
• Maintenance medication has been shown to decrease flare-ups of ulcerative colitis.
• Surgery may be required in some patients, but it is not required in every patient with ulcerative colitis.
• Routine cancer screening is a must for those who do not undergo surgical removal of the colon.

Learning about ulcerative colitis is the key to living a long and healthy life. Patient and family education will allow a better understanding of the disease and what steps may be taken to control it. Under a doctor's direction, medications, lifestyle and diet modification may be able to lengthen the time between symptom relapse.

Routine colon cancer screening should never be neglected.