Ulcerative Colitis

Author:  Frank W. Jackson, M.D.

Ulcerative colitis is a chronic, recurring disease of the large bowel. The large bowel (colon) is the 5 to 6 foot segment of intestine that begins in the right-lower abdomen, extends upward and then across to the left side, and downward to the rectum. It dehydrates the liquid stool that enters it and stores the formed stool until a bowel movement occurs.

When ulcerative colitis affects the colon, inflammation and ulcers, or sores, form in the lining of the colon. The disease may involve the entire colon (pancolitis), only the rectum (ulcerative proctitis) or, more commonly, somewhere between the two.

Causes

The cause of ulcerative colitis is unknown. Some experts believe there may be a defect in the immune system in which the body’s antibodies actually injure the colon. Others speculate that an unidentified microorganism or germ is responsible for the disease. It is probable that a combination of factors, including heredity, may be involved in the cause.

Who Develops Ulcerative Colitis?

The disorder can occur in both sexes, all races and all age groups. It is a disease that usually begins in young people.

Symptoms

The disorder typically begins gradually, with crampy abdominal pain and diarrhea that is sometimes bloody. In more severe cases, diarrhea is very severe and frequent. Loss of appetite and weight loss occur. The patient may become weak and very sick. When the disease is localized to the rectum, the symptoms are rectal urgency and passage of small amounts of bloody stool. Usually the symptoms tend to come and go, and there may be long periods without any symptoms at all. Usually, however, they recur.

Diagnosis

Diagnosis of ulcerative colitis can be suspected from the symptoms. Certain blood and stool tests are performed to rule out an infection that can mimic the disorder. A visual examination of the lining of the rectum and lower colon (sigmoidoscopy) or the entire colon (colonoscopy) is always required. This exam typically reveals a characteristic pattern. Small, painless biopsies are taken which show certain features of ulcerative colitis. Laboratory work is now available to further confirm the diagnosis.

Complications

Most patients with this disease respond well to treatment and go about their lives with few interruptions. However, some attacks may be quite severe, requiring a period of bowel rest, hospitalization and intravenous treatment. In rare cases, emergency surgery is required. The disease can affect nutrition causing poor growth during childhood and adolescence. Liver, skin, eye or joint (arthritis) problems occasionally occur, even before the bowel symptoms develop. Other problems can include narrowing and partial blocking of the bile ducts which carry bile from the liver to the intestine. Fortunately, there is much that can be done about all of these complications.

When the disease has been present for many years, the major concern is colon cancer. The risk of developing colon cancer increases significantly when the disorder begins in childhood, has been present for 8 to 10 years, or when there is a family history of colon cancer. In these situations, it is particularly important to perform regular and thorough surveillance of the colon, even when there are no symptoms. Analysis of colon biopsies performed during colonoscopy can often predict if colon cancer will occur. In these cases, preventive surgery is recommended.

Treatment

There are several types of medical treatments available:

  • Steroids (Prednisone is commonly used) — powerful drugs usually provide highly effective results. A high dose is often used initially to bring the disorder under control. Then the drug is tapered down and then usually stopped. These medications are given by pill, enema or intravenously during an acute attack. In time, the physician will usually try to discontinue these drugs because of potential long-term, adverse side effects.
  • Other Anti-inflammatory Drugs — There are increasing numbers of these drugs available. They can be given by pill or enema. The generic and trade names of some of these drugs are sulfasalazine (Azulfidine), olsalazine (Dipentum), mesalamine (Asacol, Pentasa, Lialda, Apriso, Delzicol, and Rowasa) and balsalazide (Colazal).
  • Immune System Suppressors — An overactive immune system is probably important in causing ulcerative colitis. Certain drugs such as azathioprine (Imuran), 6-MP (Purinethol), cyclosporine (Neoral, Sandimmune), and methotrexate (Rheumatrex) suppress the immune system and at times are effective.
  • Biologics — Over the past years, biologic medications called anti-TNF agents and anti-alpha4beta7 have become effective therapies.  Anti-TNF medications include infliximab (Remicade), adalimumab (Humira) and certolizumab (Cimzia). Binders to alpha4beta7 integrin include Vedolizumab (Entyvio).

Diet and Emotions

There are no foods known to injure the bowel. However, during an acute phase of the disease, bulky foods, milk, and milk products can increase diarrhea and cramping. Generally, the patient is advised to eat a healthy, well-balanced diet with adequate protein and calories. A multiple vitamin is often recommended. Iron may be prescribed if anemia is present.

Stress and anxiety may aggravate symptoms of the disorder, but are not believed to cause it or make it worse. Any chronic disease can produce a serious emotional reaction in the patient. This can usually be handled through discussion with the physician. There are excellent support groups available in most communities. The Crohn’s and Colitis Foundation is one of them.

Surgery

For patients with longstanding disease that is difficult or impossible to control with medicine, surgery is a welcomed option. In these rare cases, the patient’s lifestyle and general health have been significantly affected. Surgical removal of the colon cures the disease and returns good health and a normal lifestyle to the patient. In the past a permanent bag, or ileostomy, was required for this surgery. Advances in surgery now can avoid this problem. The colon is removed and a pouch or reservoir is created from the small intestine. Three to six liquid bowel movements occur daily. Most patients are often extremely pleased with this new surgery.

Summary

Most people with ulcerative colitis lead normal, active lives with few restrictions. Although there is no cure (except by surgery), the disorder can be managed with present treatments. For a few patients, the course of the disease may be more difficult and complicated, requiring more testing and intensive therapy. Surgery sometimes is required. In all cases, follow-up care with the physician is essential to monitor the disease and prevent and treat any complications that arise.

 

Author: Frank W. Jackson, M.D.