- Overview of Ulcerative Colitis
- Ulcerative Colitis Symptoms
- Comparison to Crohn’s disease
- Ulcerative Colitis Causes
- Ulcerative Colitis Diagnosis
- Course & Complications
- Ulcerative Colitis Treatment
More and more people are researching ulcerative colitis (UC) — they do this to educate themselves and potentially avoid health problems caused by prescription and over the counter drugs designed as ulcerative colitis treatments. Unfortunately, mostulcerative colitis drugs are synthetic and can cause an array of defects and side-effects.
Before we begin the educational coverage of Ulcerative colitis, and if this is your first time here, we’d like to welcome you. This page is dedicated to helping you learn and better understand ulcerative colitis. We firmly believe expanding your understanding of UC is the first step in over coming it.
Ulcerative colitis (UC) is a chronic long-term condition. It is a form of inflammatory bowel disease which causes swelling, ulceration and loss of function of the colon (large intestine) and rectum. Inflammatory bowel disease (IBD) is a term used to describe two diseases, ulcerative colitis and Crohn’s disease, which cause inflammation of the bowel.
Colitis most commonly affects the rectum and the the sigmoid colon (lower part of the colon) but can involve all of the colon. When only the rectum is involved it is sometimes called ulcerative proctitis or just proctitis. When the entire colon is involved it is sometimes called pancolitis.
Ulcerative colitis can affect people at any age but most commonly occurs in young adults between the ages of 15 and 25 years. The condition also has an increased incidence between the ages of 50 and 70 years. Women are more commonly affected by the condition than men. Children are rarely affected.
Ulcerative colitis is a rare disease, with an incidence of about one person per 10,000 in North America. The disease tends to be more common in northern areas.
Up to 20 percent of people suffering from ulcerative colitis have a relative or a family member with ulcerative colitis or Crohn’s disease. People of Jewish descent and whites have a higher incidence of ulcerative colitis.
Types of Colitis
- Chemical Colitis
- Collagenous Colitis
- Diversion Colitis
- Infectious Colitis
- Ischemic Colitis
- Lymphocytic Colitis
- Microscopic Colitis
About 50 percent of the people who have ulcerative colitis have mild symptoms. People with ulcerative colitis can develop pain in the abdomen, have weight loss, experience diarrhea (blood and mucus) and tiredness. Some people may also experience nausea and vomiting, fever, and mouth ulcers. The most common ulcerative colitis symptoms are episodes of bloody diarrhea and pain in the lower abdomen. There may also be a sensation of urgent need to pass a bowel motion. The bowel motions may be explosive and may contain mucous or pus. For others, ulcerative colitis symptoms vary in intensity and severity, and may come on suddenly or develop slowly.
Other UC symptoms that may be experienced include:
- weight loss
- loss of appetite
- rectal bleeding
- loss of body fluids and nutrients
- skin lesions
- joint pain
- growth failure (specifically in children)
Extent of Involvement
Ulcerative colitis is normally continuous from the rectum up the colon. The disease is classified by the extent of involvement, depending on how far up the colon the disease extends:
- Distal colitis, potentially treatable with enemas:
- Proctitis: Involvement limited to the rectum.
- Proctosigmoiditis: Involvement of the rectosigmoid colon, the portion of the colon adjacent to the rectum.
- Left-sided colitis: Involvement of the descending colon, which runs along the patient’s left side, up to the splenic flexure and the beginning of the transverse colon.
- Extensive colitis, inflammation extending beyond the reach of enemas:
- Pancolitis: Involvement of the entire colon, extending from the rectum to the cecum, beyond which the small intestine begins.
Severity of disease
In addition to the extent of involvement, UC patients may also be characterized by the severity of their disease.
- Mild disease correlates with fewer than four stools daily, with or without blood, no systemic signs of toxicity, and a normal erythrocyte sedimentation rate (ESR). There may be mild abdominal pain or cramping. Patients may believe they are constipated when in fact they are experiencing tenesmus, which is a constant feeling of the need to empty the bowel accompanied by involuntary straining efforts, pain, and cramping with little or no fecal output. Rectal pain is uncommon.
- Moderate disease correlates with more than four stools daily, but with minimal signs of toxicity. Patients may display anemia (not requiring transfusions), moderate abdominal pain, and low grade fever, 38 to 39 °C (99.5 to 102.2 °F).
- Severe disease, correlates with more than six bloody stools a day, and evidence of toxicity as demonstrated by fever, tachycardia, anemia or an elevated ESR.
- Fulminant disease correlates with more than ten bowel movements daily, continuous bleeding, toxicity, abdominal tenderness and distension, blood transfusion requirement and colonic dilation (expansion). Patients in this category may have inflammation extending beyond just the mucosal layer, causing impaired colonic motility and leading to toxic megacolon. If the serous membrane is involved, colonic perforation may ensue. Unless treated, fulminant disease will soon lead to death.
As ulcerative colitis is a systemic disease, patients may present with symptoms and complications outside the colon. These include the following:
- Aphthous ulcers of the mouth
- Ophthalmic (involving the eyes):
- Iritis or uveitis, which is inflammation of the iris
- Seronegative arthritis, which can be a large-joint oligoarthritis (affecting one or two joints), or may affect many small joints of the hands and feet
- Ankylosing spondylitis, arthritis of the spine
- Sacroiliitis, arthritis of the lower spine
- Cutaneous (related to the skin):
- Erythema nodosum, which is a panniculitis, or inflammation of subcutaneous tissue involving the lower extremities
- Pyoderma gangrenosum, which is a painful ulcerating lesion involving the skin
- Deep venous thrombosis and pulmonary embolism
- Autoimmune hemolytic anemia
- Clubbing, a deformity of the ends of the fingers
- Primary sclerosing cholangitis, or inflammation of the bile duct
Comparison to Crohn’s Disease
The most common disease that mimics the symptoms of ulcerative colitis is Crohn’s disease, as both are inflammatory bowel diseases that can affect the colon with similar symptoms. It is important to differentiate these diseases, since the course of the diseases and treatments may be different. In some cases, however, it may not be possible to tell the difference, in which case the disease is classified as indeterminate colitis.
|Factor||Crohn’s Disease||Ulcerative Colitis|
|Involves terminal ileum||Commonly||Seldom|
|Bile duct involvement||Not associated||Higher rate of Primary sclerosing cholangitis|
|Distribution of Disease||Patchy areas of inflammation||Continuous area of inflammation|
|Endoscopy||Linear and serpiginous (snake-like) ulcers||Continuous ulcer|
|Depth of inflammation||May be transmural, deep into tissues||Shallow, mucosal|
|Fistulae, abnormal passageways between organs||Commonly||Seldom|
|Biopsy||Can have granulomata|
|Surgical cure||Often returns following removal of affected part||Usually cured by removal of colon|
|Smoking||Higher risk for smokers||Lower risk for smokers|
|Autoimmune disease||Generally regarded as an autoimmune disease||No consensus|
|Cancer risk||Lower than ulcerative colitis||Higher than Crohn’s|
The exact cause of ulcerative colitis is unknown. People with ulcerative colitis have abnormalities of the immune system, the body’s immune system is believed to react abnormally to the bacteria in the digestive tract. Some experts believe there may be a genetic cause. Factors such as stress and eating certain foods do not cause ulcerative colitis but may worsen the symptoms.
The incidence of ulcerative colitis in North America is 10-12 cases per 100,000, with a peak incidence of ulcerative colitis occurring between the ages of 15 and 25. There is thought to be a bimodal distribution in age of onset, with a second peak in incidence occurring in the 6th decade of life.
The disease affects females more than males with highest incidences in the United States, Canada, the United Kingdom, and Scandinavia. Higher incidences are seen in northern locations compared to southern locations in Europe and the United States.
The initial diagnostic workup for ulcerative colitis includes the following:
- A complete blood count is done to check for anemia; thrombocytosis, a high platelet count, is occasionally seen
- Electrolyte studies and renal function tests are done, as chronic diarrhea may be associated with hypokalemia, hypomagnesemia and pre-renal failure.
- Liver function tests are performed to screen for bile duct involvement: primary sclerosing cholangitis.
- Stool culture, to rule out parasites and infectious causes.
- Erythrocyte sedimentation rate can be measured, with an elevated sedimentation rate indicating that an inflammatory process is present.
- C-reactive protein can be measured, with an elevated level being another indication of inflammation.
When a person has experienced symptoms of rectal bleeding, intermittent diarrhea and abdominal pain, ulcerative colitis may be suspected. In order to diagnose ulcerative colitis, your physician will help to perform one or more tests or procedures. These include blood tests, stool sample, flexible sigmoidoscopy, colonoscopy, barium enema, x-ray, and/or a CT scan. These tests will also help your physician rule out other conditions such as diverticulitis, Crohn’s disease, irritable bowel syndrome, and colon cancer.
If ulcerative colitis is suspected, endoscopy may be recommended. Endoscopy is the most important diagnostic test used to diagnose ulcerative colitis. During this test a small flexible tube (an endoscope) with a fiber-optic camera at its tip is passed into the rectum and colon. The doctor is able to see the lining of the rectum and colon on a television screen and can look for signs of inflammation and ulceration that may indicate ulcerative colitis. Small tissue samples (biopsies) from the lining of the colon and rectum can be taken for testing. Ulcerative colitis can be diagnosed by the characteristic abnormalities of this tissue.
X-ray tests using barium (a chalky liquid that is able to be seen on x-rays) can be helpful in determining how much of the colon is affected by ulcerative colitis. The barium is administered into the rectum and colon via a tube inserted through the anus. A series of x-rays is taken, showing the outline of the inside of the colon and highlighting any abnormalities.
Biopsies of the mucosa are taken to definitively diagnose UC and differentiate it from Crohn’s disease, which is managed differently clinically. Microbiological samples are typically taken at the time of endoscopy. The pathology in ulcerative colitis typically involves distortion of crypt architecture, inflammation of crypts (cryptitis), frank crypt abcesses, and hemorrhage or inflammatory cells in the lamina propria. In cases where the clinical picture is unclear, the histomorphologic analysis often plays a pivotal role in determining the management.
Course & Complications
Patients with ulcerative colitis usually have an intermittent course, with periods of disease inactivity alternating with “flares” of disease. Patients with proctitis or left-sided colitis usually have a more benign course: only 15% progress proximally with their disease, and up to 20% can have sustained remission in the absence of any therapy. Patients with more extensive disease are less likely to sustain remission, but the rate of remission is independent of the severity of disease.
Ulcerative Colitis and Colorectal Cancer
There is a significantly increased risk of colorectal cancer in patients with ulcerative colitis after 10 years if involvement is beyond the splenic flexure. Those with only proctitis or rectosigmoiditis usually have no increased risk. It is recommended that patients have screening colonoscopies with random biopsies to look for dysplasia after eight years of disease activity.
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.
Primary Sclerosing Choloangitis (PSC)
Ulcerative colitis has a significant association with primary sclerosing cholangitis (PSC), a progressive inflammatory disorder of small and large bile ducts. As many as 5% of patients with ulcerative colitis may progress to develop primary sclerosing cholangitis.
Ulcerative Colitis Treatment
Standard treatment for ulcerative colitis depends on extent of involvement and disease severity. The goal is to induce remission initially with medications, followed by the administration of maintenance medications to prevent a relapse of the disease. The medications used to induce and maintain a remission somewhat overlap, but the treatments are different. Physicians first direct treatment to inducing a remission which involves relief of symptoms and mucosal healing of the lining of the colon and then longer term treatment to maintain the remission.
Dietary adjustments and lifestyle changes may be enough to curb symptoms of mild cases of ulcerative colitis. Avoiding stress, eliminating dairy products, drinking more liquids, taking probiotics, eating smaller meals, and avoiding problem foods and beverages such as carbonated drinks, caffeine, and gassy foods may help to keep your symptoms in check.
When lifestyle changes and dietary adjustments do not relieve your ulcerative colitis symptoms, your doctor may advise drug therapy, which includes immune system suppressors, anti-inflammatory medications, and nicotine patches. To help you manage your symptoms, your physician may also recommend other medications such as acetaminophen, no steroidal anti-inflammatory drugs, antibiotics, anti-diarrhea medication, and iron supplements (if you have anemia). Drugs aren’t always a viable solution, however, as most have long-term side effects. You and your doctor and can decide on the benefits of drug treatment vs. their effects.
If you adjusted your diet, made lifestyle changes, and tried drug therapy with no relief from your ulcerative colitis symptoms, your doctor may recommend that you have surgery. As is often the case, surgery can eliminate ulcerative colitis. However, it does come with a price. Your surgeon will likely have to remove both your entire colon and your rectum. Today, a procedure called ileoanal anastomosis eliminates the need to wear a bag to collect your stool, which allows you to expel waste in a more natural way. Approximately 25 to 40 percent of people with this condition eventually require surgery.
Alternative Therapies for Ulcerative Colitis
Other alternative drugs may be given to relax the patient or to relieve pain, diarrhea, or infection.
Comment: “Up to 50% of people with inflammatory bowel disease seek “alternative” treatments; in one survey, aloe vera was the most widely used herbal therapy by patients with this disease.” – Langmead L, et al. Randomized, double-blind, placebo controlled trial of oral aloe Vera gel for active ulcerative colitis.
Always consult your gastroenterologist regarding potential supplements you may be considering.
These medications listed bellow are usually taken on a long-term basis and can help prevent flare-ups.
Treatment for ulcerative colitis usually involves the use of anti-inflammatory medications containing a medication known as 5-aminosalicylic acid (5-ASA). These medication reduce inflammation in the colon and rectum leading to a reduction in symptoms.
Medications to suppress the immune system may be recommended:
Steroidal medications, such as prednisone, may be required and can be given either by mouth (orally), through a drip (intravenously) or into the rectum (as an enema or suppository). Antibiotics may be required if infection in colon is present. Severe flare-ups of ulcerative colitis may require hospitalization.
Dehydration caused by profuse diarrhea may need to be treated by giving fluids through a drip. Medications to relieve pain and diarrhea may also be given.
Loss of blood through the rectum over a long period of time can lead to anemia. Iron tablets may be prescribed to correct the anemia and prevent its recurrence. In cases of severe blood loss, blood transfusions may be required.
Occasionally, symptoms are severe enough that a person must 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 mineral salts. The patient may need a special diet, feeding through a vein, medications, or sometimes surgery.
Where medications have not been successful in controlling ulcerative colitis , or where the side effects of medications are intolerable, surgery may be required. Approximately 30% of all people with extensive ulcerative colitis will require surgery at some stage. The three main surgical techniques for the treatment of ulcerative colitis are:
Total proctocolectomy and ileostomy
Removing the entire colon and rectum. The end of the small intestine is brought out onto the wall of the abdomen. A collection bag is placed over the opening and fecal matter will pass into it. The bag is emptied by the person as required. The ileostomy is permanent. This type of surgery offers a permanent cure for ulcerative colitis.
Sub-total colectomy and ileorectal anastamosis
This is where most of the colon is removed, but the rectum is retained. The lower end of the small intestine is joined to the upper end of the rectum.
Ileoanal anastomosis (“Pouch operation”)
The entire colon and rectum are removed. A section of the small intestine is used to make a small pouch where fecal matter can be stored. The pouch is then attached to the anus. This surgical technique does not require a permanent ileostomy.
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 should get as much information as possible 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.