What is ulcerative colitis?
Ulcerative colitis is a disease that causes
inflammation and sores, called ulcers, in the lining of
the rectum and colon. Ulcers form where inflammation has
killed the cells that usually line the colon, then bleed
and produce pus. Inflammation in the colon also causes the
colon to empty frequently, causing diarrhea.
When the inflammation occurs in the rectum and lower
part of the colon it is called ulcerative proctitis. If
the entire colon is affected it is called pancolitis. If
only the left side of the colon is affected it is called
limited or distal colitis.
Ulcerative colitis is an inflammatory bowel disease (IBD),
the general name for diseases that cause inflammation in
the small intestine and colon. It can be difficult to
diagnose because its symptoms are similar to other
intestinal disorders and to another type of IBD called
Crohn’s disease. Crohn’s disease differs because it
causes inflammation deeper within the intestinal wall and
can occur in other parts of the digestive system including
the small intestine, mouth, esophagus, and stomach.
Ulcerative colitis can occur in people of any age, but
it usually starts between the ages of 15 and 30, and less
frequently between 50 and 70 years of age. It affects men
and women equally and appears to run in families, with
reports of up to 20 percent of people with ulcerative
colitis having a family member or relative with ulcerative
colitis or Crohn’s disease. A higher incidence of
ulcerative colitis is seen in Whites and people of Jewish
descent.
What are the symptoms of ulcerative colitis?
The most common symptoms of ulcerative colitis are
abdominal pain and bloody diarrhea. Patients also may
experience
- anemia
- fatigue
- weight loss
- loss of appetite
- rectal bleeding
- loss of body fluids and nutrients
- skin lesions
- joint pain
- growth failure (specifically in children)
About half of the people diagnosed with ulcerative
colitis have mild symptoms. Others suffer frequent fevers,
bloody diarrhea, nausea, and severe abdominal cramps.
Ulcerative colitis may also cause problems such as
arthritis, inflammation of the eye, liver disease, and
osteoporosis. It is not known why these problems occur
outside the colon. Scientists think these complications
may be the result of inflammation triggered by the immune
system. Some of these problems go away when the colitis is
treated.
What causes ulcerative colitis?
Many theories exist about what causes ulcerative
colitis. People with ulcerative colitis have abnormalities
of the immune system, but doctors do not know whether
these abnormalities are a cause or a result of the
disease. The body’s immune system is believed to react
abnormally to the bacteria in the digestive tract.
Ulcerative colitis is not caused by emotional distress
or sensitivity to certain foods or food products, but
these factors may trigger symptoms in some people. The
stress of living with ulcerative colitis may also
contribute to a worsening of symptoms.
How is ulcerative colitis diagnosed?
Many tests are used to diagnose ulcerative colitis. A
physical exam and medical history are usually the first
step.
Blood tests may be done to check for anemia, which
could indicate bleeding in the colon or rectum, or they
may uncover a high white blood cell count, which is a sign
of inflammation somewhere in the body.
A stool sample can also reveal white blood cells, whose
presence indicates ulcerative colitis or inflammatory
disease. In addition, a stool sample allows the doctor to
detect bleeding or infection in the colon or rectum caused
by bacteria, a virus, or parasites.
A colonoscopy or sigmoidoscopy are the most accurate
methods for making a diagnosis of ulcerative colitis and
ruling-out other possible conditions, such as Crohn’s
disease, diverticular disease, or cancer. For both tests,
the doctor inserts an endoscope—a long, flexible,
lighted tube connected to a computer and TV monitor—into
the anus to see the inside of the colon and rectum. The
doctor will be able to see any inflammation, bleeding, or
ulcers on the colon wall. During the exam, the doctor may
do a biopsy, which involves taking a sample of tissue from
the lining of the colon to view with a microscope.
Sometimes x rays such as a barium enema or CT scans are
also used to diagnose ulcerative colitis or its
complications.
What is the treatment for ulcerative colitis?
Treatment for ulcerative colitis depends on the
severity of the disease. Each person experiences
ulcerative colitis differently, so treatment is adjusted
for each individual.
Drug Therapy
The goal of drug therapy is to induce and maintain
remission, and to improve the quality of life for people
with ulcerative colitis. Several types of drugs are
available.
- Aminosalicylates, drugs that contain
5-aminosalicyclic acid (5-ASA), help control
inflammation. Sulfasalazine is a combination of
sulfapyridine and 5-ASA. The sulfapyridine component
carries the anti-inflammatory 5-ASA to the intestine.
However, sulfapyridine may lead to side effects such
as nausea, vomiting, heartburn, diarrhea, and
headache. Other 5-ASA agents, such as olsalazine,
mesalamine, and balsalazide, have a different carrier,
fewer side effects, and may be used by people who
cannot take sulfasalazine. 5-ASAs are given orally,
through an enema, or in a suppository, depending on
the location of the inflammation in the colon. Most
people with mild or moderate ulcerative colitis are
treated with this group of drugs first. This class of
drugs is also used in cases of relapse.
- Corticosteroids such as prednisone,
methylprednisone, and hydrocortisone also reduce
inflammation. They may be used by people who have
moderate to severe ulcerative colitis or who do not
respond to 5-ASA drugs. Corticosteroids, also known as
steroids, can be given orally, intravenously, through
an enema, or in a suppository, depending on the
location of the inflammation. These drugs can cause
side effects such as weight gain, acne, facial hair,
hypertension, diabetes, mood swings, bone mass loss,
and an increased risk of infection. For this reason,
they are not recommended for long-term use, although
they are considered very effective when prescribed for
short-term use.
- Immunomodulators such as azathioprine and
6-mercapto-purine (6-MP) reduce inflammation by
affecting the immune system. These drugs are used for
patients who have not responded to 5-ASAs or
corticosteroids or who are dependent on
corticosteroids. Immunomodulators are administered
orally, however, they are slow-acting and it may take
up to 6 months before the full benefit. Patients
taking these drugs are monitored for complications
including pancreatitis, hepatitis, a reduced white
blood cell count, and an increased risk of infection.
Cyclosporine A may be used with 6-MP or azathioprine
to treat active, severe ulcerative colitis in people
who do not respond to intravenous corticosteroids.
Other drugs may be given to relax the patient or to
relieve pain, diarrhea, or infection.
Some people have remissions—periods when the symptoms
go away—that last for months or even years. However,
most patients’ symptoms eventually return.
Hospitalization
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.
Surgery
About 25 to 40 percent of ulcerative colitis patients
must eventually have their colons removed because of
massive bleeding, severe illness, rupture of the colon, or
risk of cancer. 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.
Surgery to remove the colon and rectum, known as
proctocolectomy, is followed by one of the following:
- Ileostomy, in which the surgeon creates a
small opening in the abdomen, called a stoma, and
attaches the end of the small intestine, called the
ileum, to it. Waste will travel through the small
intestine and exit the body through the stoma. The
stoma is about the size of a quarter and is usually
located in the lower right part of the abdomen near
the beltline. A pouch is worn over the opening to
collect waste, and the patient empties the pouch as
needed.
- Ileoanal anastomosis, or pull-through
operation, which allows the patient to have normal
bowel movements because it preserves part of the anus.
In this operation, the surgeon removes the colon and
the inside of the rectum, leaving the outer muscles of
the rectum. The surgeon then attaches the ileum to the
inside of the rectum and the anus, creating a pouch.
Waste is stored in the pouch and passes through the
anus in the usual manner. Bowel movements may be more
frequent and watery than before the procedure.
Inflammation of the pouch (pouchitis) is a possible
complication.
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.
Is colon cancer a concern?
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.
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