What is Ulcerative Colitis?
Ulcerative colitis is a disease in which there is chronic inflammation of the inner lining of the colon. The inflammation can cause the lining tissue to break down, forming ulcerations that can bleed. Inflammation can involve the entire colon or only parts of it. Almost always, ulcerative colitis requires treatment.
Warning Sign: Abdominal Pain
The main symptoms caused by ulcerative colitis are abdominal pain and diarrhea, usually bloody. Symptoms vary in severity from mild to severe. The photograph shows the typical pattern of ulcerative colitis with ulcerations covered by white pus.
Warning Sign: Weight Loss
The chronic inflammation and symptoms of ulcerative colitis, if not controlled, have general effects on nutrition; poor appetite, loss of weight, and poor growth in children are common.
Other Warning Signs
Associated with the colonic inflammation in ulcerative colitis are complications that are not a direct result of the inflammation in the colon. Some of these complications are generalized symptoms and signs of inflammation such as fever, fatigue, and anemia. Others are the result of inflammation occurring outside of the colon such as arthritis and skin sores.
Ulcerative Colitis or Crohn’s Disease?
Ulcerative colitis is related to Crohn's disease, another chronic inflammatory disease of the intestines (both are referred to as inflammatory bowel disease); however, Crohn's disease, unlike ulcerative colitis, is not limited to the colon. In fact, Crohn's disease usually involves the small intestine or small intestine and colon although occasionally it, too, is limited to the colon. Another chronic gastrointestinal disorder, irritable bowel syndrome, shares with ulcerative colitis abdominal pain and diarrhea as its main symptoms; however, the cause of irritable bowel syndrome is believed to be dysfunction of the nerves and muscles of the intestines since there is no identifiable inflammation.
Who is Affected by Ulcerative Colitis?
Ulcerative colitis is a disease that occurs in developed nations, and is more common in cities than in the countryside. Approximately 1 million people in the U.S. suffer from ulcerative colitis. Individuals with ulcerative colitis usually develop the disease between ages 15 and 25 although the disease may begin at any age. There seems to be a genetic component since ulcerative colitis is more common among relatives of individuals with ulcerative colitis. Caucasians and individuals of eastern European Jewish descent are more likely to develop ulcerative colitis.
What Causes Ulcerative Colitis?
The cause of ulcerative colitis is unknown, but it is believed to be somehow related to abnormal immunologic reactions of the body to the bacteria normally found in the colon. There is no evidence that diet is the cause of ulcerative colitis.
Diagnosing Ulcerative Colitis
The best way of diagnosing ulcerative colitis is with colonoscopy, a procedure in which a camera on the end of a long flexible tube is passed through the anus and into the colon and then traverses the entire colon. Although ulcerative colitis also can be diagnosed by barium enema, a procedure that requires X-rays of a barium-filled colon, colonoscopy is more sensitive, that is, it identifies lower levels of inflammation than can be identified by barium enema. Colonoscopy also allows biopsies to be taken of the colonic lining to confirm the diagnosis.
The Course of Ulcerative Colitis
The course of ulcerative colitis is variable. Untreated, it usually fluctuates in severity from mild to severe in the same individual, most often over years. Occasionally, the disease "burns out," becoming inactive although residual scarring usually is visible with colonoscopy.
Urgent Care for Ulcerative Colitis
During a flare of ulcerative colitis, treatment is important to avoid complications. The most common complication is bleeding that can lead to anemia. With a severe flare, the colon may stop working and dilate (enlarge). If not successfully treated, the colon may rupture and become a medical emergency. If treatment is not successful, surgery may be necessary. Usually, the entire colon is removed.
Ulcerative Colitis and Colon Cancer
Individuals with ulcerative colitis are at increased risk for colon cancer. The risk of colon cancer increases while the duration of disease and the extent of the disease in the colon increase. To prevent colon cancer, screening colonoscopy with biopsies are recommended on a regular basis (usually annually) in order to detect precancerous cells so that the colon can be removed surgically before cancer develops. Screening usually is begun approximately eight years after the onset of the disease, the time at which the incidence of colon cancer begins to increase.
Ulcerative colitis is associated with important complications in parts of the body unconnected with the colon. Inflammation may involve the spine and large joints (arthritis). Serious skin ulcerations may occur. A serious liver disease, sclerosing cholangitis, occurs in a small number of people with ulcerative colitis. All of these complications involve inflammation and the immune system just like in the colon. Some of these complications improve with successful treatment of the colitis, others do not.
Medications for Ulcerative Colitis
Treatment of ulcerative colitis aims to reduce the inflammation in the colon. The inflammation-reducing drugs with the most extensive experience are the aminosalicylates, drugs that are related to aspirin. If aminosalicylates are ineffective, corticosteroids (for example, prednisone) are used. A third type of drug that is used is immunomodulators, drugs that reduce the immune response and thereby the inflammation. It may take several weeks to months for the drugs to become maximally effective. Biologics like adalimumab and others target proteins produced by the immune system.
The most recent innovation in the treatment of ulcerative colitis is what is referred to as biologic therapy. Biologic therapy is therapy with antibodies that are directed against molecules that the immune system produces and that cause the inflammation. The biologic therapy with the most experience is directed against a protein produced by the immune system called tumor necrosis factor. The antibodies must be given intravenously every few weeks.
An interesting observation is that infection with the pig whipworm may be effective treatment for ulcerative colitis. Scientists believe that the worms that inhabit the colon alter the immune response and thereby reduce the inflammation. In one study, 43% of patients with ulcerative colitis improved after ingesting pig whipworm eggs for 12 weeks. The impetus for investigating treatment with the whipworm came from the observation that ulcerative colitis was not common in developing countries where intestinal parasitic diseases are common.
Surgery for Ulcerative Colitis
Despite drug therapies, approximately one-third of people with ulcerative colitis will need surgery to treat the inflammation, prevent or treat cancer, or to treat a complication such as rupture of the colon. Surgery in which the entire colon is removed cures the person of their ulcerative colitis. In the past they were left with ileostomies, external bags into which the small intestine emptied. Surgical techniques have been developed, however, that now allow the colon to be removed without the need for an ileostomy.
Ulcerative Colitis in Children
Children with ulcerative colitis that is not controlled often grow more slowly than normal, and may end up shorter than they would have. This occurs because when there is active inflammation, appetite is reduced and an insufficient amount of food is eaten. It may be necessary to recommend high calorie diets or even augment the diet with supplements. Children with psycho-social problems because of their disease may need a therapist to help them develop strategies to cope with the disease.
Living With UC: Reducing Flares
There are few non-drug, controllable factors that can reduce the symptoms of ulcerative colitis. Stress reduction is important although it probably makes the symptoms seem less severe without actually reducing them. Of course, it is of utmost importance for patients to take their medications regularly and not miss doses. Although smoking can reduce the inflammation of ulcerative colitis, smoking cannot be recommended as treatment because of its many other detrimental effects.
Living With UC: Diet Changes
Although it has not been found that diet has an effect on ulcerative colitis, it generally is recommended that patients eliminate any foods that they find are making their symptoms worse. For example, milk in people with UC who are intolerant to the sugar in milk, lactose, may be causing gastrointestinal symptoms such as abdominal bloating, flatulence, and diarrhea, symptoms that may overlap with those of ulcerative colitis. Despite not being the cause of the ulcerative colitis, eliminating milk may improve gastrointestinal symptoms in these people. It is important to be sure that the diet is nutritionally adequate, and this may require the assistance of a dietician.
Living With UC: Supplements
The bleeding caused by ulcerative colitis may lead to iron deficiency anemia due to the loss of the body's store of iron in the red blood cells that are lost into the colon. Iron supplementation may be necessary. Medications used to treat ulcerative colitis may reduce the absorption of nutrients such as folic acid and calcium. Supplements of vitamins and minerals may be necessary.
Living With UC: Probiotics
Probiotics consist of bacteria that confer a health benefit on the person who ingests them. In general, they are bacteria that are normally found in the human intestine. Probiotics have beneficial effects in several medical conditions. Studies have shown that probiotics help people with ulcerative colitis maintain their remissions. Probiotics are found in yogurts and some other foods, but the probiotics that have been studied and found to be effective are sold separately as supplements and are not food products. The effects of probiotics vary greatly and depend on the exact bacteria that are present. Therefore, it is likely that many probiotics that are sold have no beneficial effect, and, therefore, the one that is used for treatment needs to be chosen carefully on the basis of scientific studies.
Chronic diarrhea can lead to dehydration, particularly if individuals feel ill and are not eating or drinking enough fluids. It is important to maintain an adequate fluid intake. The simplest way to judge whether intake is adequate is to look at the volume and color of urine each the day. A small amount or a dark color of the urine suggests that the intake of water is not adequate. A suggested amount of liquid to drink each day is half an ounce per pound of weight.
Ulcerative colitis can have a major effect on relationships, particularly intimate ones. Issues of feeling ill or needing to visit the restroom frequently can be socially limiting. Both of these issues can be controlled by adequate treatment of the ulcerative colitis. Medications, for example, corticosteroids can cause changes in mood such as depression or euphoria. Libido also can be reduced. It is important to be open about these issues with intimate partners and with physicians. It may be of value to see a specialist - psychologist or psychiatrist - to help deal with the issues.
People with ulcerative colitis in remission usually have no problems when traveling. If some symptoms are present, it may be necessary to take several precautionary steps including:
- Ask employees or use web sites to learn where bathrooms are located in airports and other public buildings ahead of a visit.
- Carry a change of underwear and moist towlettes
- Make sure that enough medication is taken to last the entire trip. It probably also is valuable to take copies of prescriptions in case a visit to a medical facility is necessary.
- Discuss your plans for the trip with a doctor to determine if any other steps should be taken, for example, taking additional medications in case symptoms become problematic or a flare of the disease occurs.