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Ulcerative Colitis

Definition:
More than 500,000 Americans have ulcerative colitis, an inflammatory bowel disease (IBD) that causes chronic inflammation of the digestive tract. Like Crohn's disease, another common IBD, ulcerative colitis can be painful and debilitating and sometimes can lead to life-threatening complications.

Ulcerative colitis and Crohn's disease are similar — so similar that they're often mistaken for one another. Both inflame the lining of your digestive tract, and both can cause severe bouts of watery or bloody diarrhea and abdominal pain. But ulcerative colitis usually affects only the innermost lining of your large intestine (colon) and rectum. Crohn's disease, on the other hand, can occur anywhere in your digestive tract, often spreading deep into the layers of affected tissues.

There's no known medical cure for ulcerative colitis, but therapies are available that may dramatically reduce the signs and symptoms of ulcerative colitis and even bring about a long-term remission.

Causes :
Like Crohn's disease, ulcerative colitis causes inflammation and ulcers in your intestine. But unlike Crohn's, which can occur in patches anywhere along the digestive tract, ulcerative colitis usually affects a continuous section of the inner lining of the colon beginning with the rectum.

No one is quite sure what triggers ulcerative colitis, but there's a consensus as to what doesn't. Researchers no longer believe that stress is the main culprit, although stress can often aggravate symptoms. Instead, current thinking focuses on the following possibilities:
  • Immune system. Some scientists think a virus or bacterium may cause ulcerative colitis. The digestive tract becomes inflamed when the body's immune system tries to fight off the invading microorganism. It's also possible that inflammation may stem from the virus or bacterium itself or from an autoimmune reaction in which the body mounts an immune response even though no pathogen is present.
  • Heredity. Because you're more likely to develop ulcerative colitis if you have a parent or sibling with the disease, scientists suspect that genetic makeup may play a contributing role. Research into which genetic mutations might increase susceptibility to ulcerative colitis is ongoing.
  • Environment. Because ulcerative colitis occurs more often among people living in cities and industrial nations, it's possible that environmental factors, including a diet high in fat or refined foods, may play a role.
  • Antibiotics. Antibiotic therapy can lead to acute colitis or to pseudomembranous colitis, a particularly serious disease. These problems occur because antibiotics disrupt the normal balance of bacteria in your intestinal tract. But researchers haven't found a clear link between antibiotics and ulcerative colitis.
Risk Factor:
Ulcerative colitis affects about the same number of women and men. Risk factors may include:
  • Age. Ulcerative colitis can strike at any age, but you're most likely to develop the condition when you're young. Ulcerative colitis often strikes people in their 30s, although a small number of people may not develop the disease until the sixth or seventh decade of life.
  • Ethnicity. Although whites have the highest risk of the disease, it can strike any ethnic group. If you're Jewish and of European descent, you're four to five times as likely to have ulcerative colitis.
  • Family history. You're at higher risk if you have a close relative, such as a parent, sibling or child, with the disease.
  • Where you live. If you live in an urban area or in an industrialized country, you're more likely to develop ulcerative colitis. People living in Northern climates also seem to have a greater risk of ulcerative colitis.
When to seek medical advice:
See your doctor if you experience a persistent change in your bowel habits or if you have any of the signs and symptoms of ulcerative colitis, such as abdominal pain, blood in your stool, ongoing bouts of diarrhea that don't respond to over-the-counter (OTC) medications or an unexplained fever lasting more than a day or two.

Although ulcerative colitis usually isn't fatal, it's a serious disease that, in some cases, may cause life-threatening complications.

Symptoms:
The signs and symptoms of ulcerative colitis can vary widely, depending on the severity of inflammation and where it occurs. For that reason, doctors often classify ulcerative colitis according to its location. Here are the signs and symptoms that may accompany ulcerative colitis, depending on its classification:
  • Ulcerative proctitis. In this form of ulcerative colitis, inflammation is confined to the rectum and for some people, rectal bleeding may be the only sign of the disease. Others may have rectal pain, a feeling of urgency or an inability to move the bowels in spite of the urge to do so (tenesmus).
  • Left-sided colitis.   As the name suggests, inflammation extends from the rectum up the left side through the sigmoid and descending colon. Signs and symptoms include bloody diarrhea, abdominal cramping and pain, and weight loss.
  • Pancolitis. Affecting the entire colon, pancolitis causes bouts of bloody diarrhea that may be severe, abdominal cramps and pain, fatigue, weight loss, and night sweats.
  • Fulminant colitis. This rare, life-threatening form of colitis affects the entire colon and causes severe pain, profuse diarrhea, and sometimes, dehydration and shock. People with fulminant colitis are at risk of serious complications including colon rupture and toxic megacolon, which occurs when the colon becomes severely distended.

The course of ulcerative colitis varies, with periods of acute illness often alternating with periods of remission. But over time, the severity of the disease usually remains the same. Only a small percentage of people with a milder condition such as ulcerative proctitis go on to develop more severe signs and symptoms.


Dignosis:
Your doctor will likely diagnose ulcerative colitis only after ruling out other possible causes for your signs and symptoms, including irritable bowel syndrome (IBS), diverticulitis and colorectal cancer. To help confirm a diagnosis of ulcerative colitis, you may have one or more of the following tests and procedures:
  • Blood tests. Your doctor may suggest blood tests to check for anemia or signs of infection. Two tests that look for the presence of certain antibodies can sometimes help diagnose which type of inflammatory bowel disease you have, but not everyone with ulcerative colitis or Crohn's disease has these antibodies. These tests are not sensitive enough for routine use but may be helpful in specific circumstances.
  • Colonoscopy. This is the most sensitive test for diagnosing ulcerative colitis or Crohn's disease. It allows your doctor to view your entire colon using a thin, flexible, lighted tube with an attached camera. During the procedure, your doctor can also take small samples of tissue (biopsy) for laboratory analysis. Sometimes a tissue sample can help confirm a diagnosis. If there are clusters of inflammatory cells called granulomas, for instance, it's likely you have Crohn's disease, because granulomas don't occur with ulcerative colitis. Risks of this procedure include perforation of the colon wall and bleeding, especially when a biopsy is taken.
  • Flexible sigmoidoscopy. In this procedure, your doctor uses a slender, flexible, lighted tube to examine the sigmoid, the last 2 feet of your colon. The test usually takes just a few minutes. It's somewhat uncomfortable, and there's a slight risk of perforating the colon wall. It may also miss problems higher up in your colon.
  • Barium enema. This diagnostic test allows your doctor to evaluate your entire large intestine with an X-ray. Barium, a contrast dye, is placed into your bowel in an enema form. Sometimes, air is added as well. The barium fills and coats the lining of the bowel, creating a silhouette of your rectum, colon and a portion of your small intestine. Barium enema isn't as reliable as colonoscopy, it doesn't allow your doctor to take tissue samples, and it's not used in people with moderate to severe disease because of the risk of complications.
  • Small bowel X-ray. This test looks at the part of the small bowel that can't be seen by colonoscopy. You drink a barium "shake" before the procedure, and X-rays are the taken of your small intestine. This test can be helpful in distinguishing between ulcerative colitis and Crohn's disease.
Complication:
The most serious acute complication of ulcerative colitis is toxic megacolon. This occurs when your colon becomes paralyzed, preventing you from having a bowel movement or passing gas. Signs and symptoms include abdominal pain and swelling, fever and weakness. You might also become disoriented or groggy. If toxic megacolon isn't treated, your colon may rupture, causing peritonitis, a life-threatening condition requiring emergency surgery.

Other possible complications of ulcerative colitis include:
  • Perforated colon
  • Severe dehydration
  • Liver disease
  • Inflammation of the skin, joints and eyes
IBD and colon cancer
Both ulcerative colitis and Crohn's disease increase your risk of colon cancer. Despite this increased risk, however, more than 90 percent of people with inflammatory bowel disease never develop cancer. Your risk is greatest if you've had inflammatory bowel disease for at least eight to 10 years and if it has spread through your entire colon. You're less likely to develop cancer if only a small part of your colon is diseased.

Pregnancy
If you have ulcerative colitis, consult your doctor before becoming pregnant or fathering a child. Some medications used to treat IBD have the potential to cause birth defects or can be passed to the baby through breast milk. Active ulcerative colitis increases the risk of fetal death or preterm labor. If you're already pregnant, be sure you're cared for by a doctor who has experience with IBD and pregnancy.

Treatment:
The goal of medical treatment is to reduce the inflammation that triggers your signs and symptoms. In the best cases, this may lead not only to symptom relief but also to long-term remission. Treatment for ulcerative colitis usually involves either drug therapy or surgery.

Doctors use several categories of drugs that control inflammation in different ways. But drugs that work well for some people may not work for others, so it may take time to find a medication that helps you. In addition, because some drugs have serious side effects, you'll need to weigh the benefits and risks of any treatment.

Anti-inflammatory drugs
Anti-inflammatory drugs are often the first step in the treatment of inflammatory bowel disease. They include:
  • Sulfasalazine (Azulfidine). Doctors have used this drug for many years to treat ulcerative colitis. Although it can be effective in reducing symptoms of the disease, it has a number of side effects, including nausea, vomiting, heartburn and headache. Don't take this medication if you're allergic to sulfa medications.
  • Mesalamine (Asacol, Rowasa) and olsalazine (Dipentum). These medications tend to have fewer side effects than sulfasalazine has. You take them in tablet form or use them rectally in the form of enemas or suppositories, depending on the area of your colon affected by ulcerative colitis. Mesalamine enemas can relieve signs and symptoms in more than 80 percent of people with ulcerative colitis in the lower left side of their colon and rectum. Olsalazine may cause or worsen existing diarrhea in some people.
  • Balsalazide (Colazal). This is another formulation of mesalamine, the compound found in drugs such as Asacol and Rowasa. Colazal delivers anti-inflammatory medication directly to the colon. The drug is similar to sulfasalazine, but uses a less toxic carrier and may produce fewer side effects. Twenty percent of people with ulcerative colitis using this medication experience remission lasting longer than 12 weeks.
  • Corticosteroids. Steroids can help reduce inflammation, but they have numerous side effects, including a puffy face, excessive facial hair, night sweats, insomnia and hyperactivity. More serious side effects include high blood pressure, type 2 diabetes, osteoporosis, bone fractures, cataracts and an increased susceptibility to infections. Long-term use of these drugs in children can lead to stunted growth. Also, corticosteroids don't work for everyone who has ulcerative colitis. Doctors generally use corticosteroids only if you have moderate to severe inflammatory bowel disease that doesn't respond to other treatments. Corticosteroids aren't for long-term use and are generally prescribed for a period of three to four months. They may also be used in conjunction with other medications as a means to induce remission. For example, corticosteroids may be used with an immune system suppressor because the corticosteroids can induce remission, while the immune system suppressors can help maintain remission. Occasionally your doctor may also prescribe steroid enemas to treat disease in your lower colon or rectum. These, too, are only for short-term use.
  • Fish oil. The omega-3 fatty acids in fish oil have been shown to reduce inflammation in people with ulcerative colitis. One experimental therapy uses a drink containing fatty acids from fish oil, antioxidants and soluble fiber. In studies, the supplement significantly reduced the need for corticosteroid therapy.
Immune system suppressors
These drugs also reduce inflammation, but they target your immune system rather than treating inflammation itself. Because immune suppressors can be effective in treating ulcerative colitis, scientists theorize that damage to digestive tissues is caused by your body's immune response to an invading virus or bacterium or even to your own tissue. By suppressing this response, inflammation is also reduced. Immunosuppressant drugs include:
  • Azathioprine (Imuran) and mercaptopurine (Purinethol). These drugs have been used to treat Crohn's disease for years, but their role in ulcerative colitis is only now being studied. Because azathioprine and mercaptopurine act slowly, they're sometimes initially combined with a corticosteroid, but in time, they seem to produce benefits on their own, with less long-term toxicity. Side effects are not minor, however, and can include allergic reactions, bone marrow suppression, infections, and inflammation of the liver and pancreas.
  • Cyclosporine (Neoral, Sandimmune). This potent drug is normally reserved for people who don't respond well to other medications or who face surgery because of severe ulcerative colitis. In some cases, cyclosporine may be used to delay surgery until you're strong enough to undergo the procedure; in others, it's used to control signs and symptoms until less toxic drugs start working. Cyclosporine begins working in one to two weeks, but because it has the potential for severe side effects including kidney and liver damage, fatal infections and an increased risk of lymphoma, the risks and benefits of treatment must be carefully weighed.
  • Infliximab (Remicade). This drug received Food and Drug Administration approval in September 2005 for use in ulcerative colitis. It works by neutralizing a protein produced by your immune system known as tumor necrosis factor (TNF). Infliximab finds TNF in your bloodstream and removes it before it causes inflammation in your intestinal tract. Some people with heart failure and people with multiple sclerosis and those with cancer or a history of cancer can't use infliximab. If you're currently taking infliximab, talk to your doctor about the potential risks. The drug has been linked to an increased risk of infection, especially tuberculosis, and may increase your risk of blood problems and cancer. What's more, because infliximab is partly a mouse protein, it can cause serious allergic reactions in some people — reactions that may be delayed for days to weeks after starting treatment. Once started, infliximab is often continued as long-term therapy, although its effectiveness may wear off over time.
Nicotine patches
These skin patches — the same kind smokers use — seem to provide short-term relief from flare-ups of ulcerative colitis for some people, especially people who formerly smoked. How nicotine patches work isn't exactly clear, and no one should take up smoking as a treatment for ulcerative colitis. The risks from smoking far outweigh any potential benefit.

Other medications
In addition to controlling inflammation, some medications may help relieve your signs and symptoms. Depending on the severity of your ulcerative colitis, your doctor may recommend one or more of the following:
  • Anti-diarrheals. A fiber supplement such as psyllium powder (Metamucil) or methylcellulose (Citrucel) can help relieve signs and symptoms of mild to moderate diarrhea by adding bulk to your stool. For more severe diarrhea, loperamide (Imodium) may be effective. Use narcotics with great caution, however, because they increase the risk of toxic megacolon.
  • Laxatives. In some cases, swelling may cause your intestines to narrow, leading to constipation. Talk to your doctor before taking any laxatives, because even those sold over-the-counter may be too harsh for your system.
  • Pain relievers. For mild pain, your doctor may recommend acetaminophen (Tylenol, others). Don't use nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen (Advil, Motrin, others) or naproxen (Aleve). These are likely to make your symptoms worse.
  • Iron supplements. If you have chronic intestinal bleeding, you may develop iron deficiency anemia. Taking iron supplements may help restore your iron levels to normal and reduce this type of anemia once your bleeding has stopped or diminished.
New treatments
Researchers are testing the drug adalimumab (Humira), which is currently approved for treating arthritis, for use in ulcerative colitis. Like infliximab, it blocks tumor necrosis factor, but may have fewer side effects than infliximab does.

Surgery
If diet and lifestyle changes, drug therapy or other treatments don't relieve your signs and symptoms, your doctor may recommend surgery.

Surgery can often eliminate ulcerative colitis. But that usually means removing your entire colon and rectum (proctocolectomy). In the past, after this surgery you would wear a small bag over an opening in your abdomen to collect stool. But a procedure called ileoanal anastomosis eliminates the need to wear a bag. Instead, your surgeon constructs a pouch from the end of your small intestine. The pouch is then attached directly to your anus. This allows you to expel waste normally, although you may have as many as five to seven watery bowel movements a day because you no longer have your colon to absorb water. Between 25 percent and 40 percent of people with ulcerative colitis eventually need surgery.
 
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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