Ulcerative Colitis
Ulcerative colitis (UC) is a long-term condition that results in inflammation and ulcers of the colon and rectum. The primary symptoms of active disease are abdominal pain and diarrhea mixed with blood. Weight loss, fever, and anemia may also occur.
Often, symptoms come on slowly and can range from mild to severe. Symptoms typically occur intermittently with periods of no symptoms between flares. Complications may include megacolon, inflammation of the eye, joints, or liver, and colon cancer.
The cause of UC is unknown. Theories involve immune system dysfunction, genetics, changes in the normal gut bacteria, and environmental factors. Rates tend to be higher in the developed world with some proposing this be the result of less exposure to intestinal infections, or to a Western diet and lifestyle.
The removal of the appendix at an early age may be protective. Diagnosis is typically by colonoscopy with tissue biopsies. It is a kind of inflammatory bowel disease (IBD) along with Crohn’s disease and microscopic colitis.
Dietary changes, such as maintaining a high-calorie diet or lactose-free diet, may improve symptoms. Several medications are used to treat symptoms and bring about and maintain remission, including aminosalicylates such as mesalazine or sulfasalazine, steroids, immunosuppressants such as azathioprine, and biologic therapy.
Removal of the colon by surgery may be necessary if the disease is severe, does not respond to treatment, or if complications such as colon cancer development. Removal of the colon and rectum can cure the disease.
Ulcerative Colitis Types
The type of ulcerative colitis you have depends on where it’s located in your body:
- Ulcerative proctitis is usually the mildest form. It’s only in the rectum, the part of your colon closest to your anus. Rectal bleeding may be the only sign of the disease.
- Proctosigmoiditis your rectum and the lower end of your colon (you may hear the doctor call it the sigmoid colon). You’ll have bloody diarrhea, belly cramps, and pain. You’ll have the urge to poop but you won’t be able to. (Your doctor may call this tenesmus).
- Left-sided colitis causes cramps on that side of your belly. You’ll also have bloody diarrhea, and you might lose weight without trying. You’ll have inflammation from your rectum up through the left side of your colon.
- Pancolitis often affects your entire colon. It can cause severe bouts of bloody diarrhea, belly cramps, pain, fatigue, and major weight loss.
- Acute severe ulcerative colitis is rare. It affects your entire colon and causes severe pain, heavy diarrhea, bleeding, and fever.
Ulcerative Colitis Symptoms
The first symptom of ulcerative colitis is usually diarrhea.
Feces becomes progressively looser, and there may be abdominal pain with cramps and a severe urge to pass stools.
Diarrhea may begin slowly or suddenly. Symptoms depend on the extent and spread of inflammation.
The most common symptoms of ulcerative colitis include:
- abdominal pain
- bloody diarrhea with mucus
The following might also occur:
- fatigue or tiredness
- weight loss
- loss of appetite
- anemia
- elevated temperature
- dehydration
- a constant urge to pass feces
Symptoms are often worse early in the morning.
Symptoms may be mild or absent for months or years at a time. However, they will usually return without treatment and vary depending on the affected part of the colon.
Ulcerative Colitis Causes
The exact causes of ulcerative colitis are unclear. However, they may involve the following:
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Genetics
About one-fifth of people with ulcerative colitis have a close relative who has the same condition, suggesting that it is heritable.
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Environmental
The following environmental factors might affect the onset of ulcerative colitis:
- diet
- air pollution
- cigarette smoke
- poor hygiene
Immune system
The body might respond to a viral or bacterial infection in a way that causes the inflammation associated with ulcerative colitis.
Once the infection resolves, the immune system continues to respond, which leads to ongoing inflammation.
Another theory suggests that ulcerative colitis may be an autoimmune condition. A fault in the immune system may cause it to fight nonexistent infections, leading to inflammation in the colon.
Ulcerative Colitis Risk factors
Some known risk factors for ulcerative colitis include:
- Age: Ulcerative colitis can affect people at any age but is more common at 15–30 years of age.
- Ethnicity: White people have a higher risk of developing the condition, as do those of Ashkenazi Jewish descent.
- Genetics: Although recent studies have identified certain genes that may play a role in ulcerative colitis, the link is unclear due to the role of environmental factors.
Ulcerative Colitis Complications
The possible complications of ulcerative colitis range from a lack of nutrients to potentially fatal bleeding from the rectum. We cover more possible complications in the sections below:
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Colorectal cancer
Ulcerative colitis, especially if symptoms are severe or extensive, increases the risk of developing colon cancer.
According to the National Institute of Diabetes and Digestive and Kidney Diseases, colon cancer risk is highest when ulcerative colitis affects the entire colon for longer than 8 years.
Males with ulcerative colitis also have a higher risk of colon cancer than females with the condition.
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Toxic megacolon
This complication occurs in a few cases of severe ulcerative colitis.
In toxic megacolon, gas becomes trapped, causing the colon to swell. When this occurs, there is a risk of colon rupture, septicemia, and shock.
Other complications
Other possible complications of ulcerative colitis include:
- Inflammation of the skin, joints, and eyes
- Liver disease
- Osteoporosis
- Perforated colon
- Severe bleeding
- Severe dehydration
To prevent a loss of bone density, a doctor may prescribe vitamin D supplements, calcium, or other medications.
Attending regular medical appointments, closely following a doctor’s advice, and being aware of symptoms can help prevent the development of these complications.
Ulcerative Colitis Diagnosis
A doctor will ask about a person’s symptoms and medical history. They will also ask whether any close relatives have had ulcerative colitis, IBD, or Crohn’s disease.
They will also check for signs of anemia, or low levels of iron in the blood, and tenderness around the abdomen.
Several tests can help rule out other possible conditions and diseases, including Crohn’s disease, infection, and irritable bowel syndrome.
These include:
- Blood tests
- Stool tests
- X-ray
- Barium enema, during which a healthcare professional passes a fluid called barium through the colon to show any changes or anomalies in a scan
- Sigmoidoscopy, in which a healthcare professional inserts a flexible tube with a camera at the end, called an endoscope, into the rectum
- Colonoscopy, wherein a doctor examines the whole colon using an endoscope
- a CT scan of the abdomen or pelvis
Ulcerative Colitis Treatment
A person with ulcerative colitis will need to see a doctor who specializes in treating conditions of the digestive system, or a gastroenterologist.
They will assess the type and severity of the condition and create a treatment plan.
People with severe symptoms may require hospitalization, but a person with mild-to-moderate symptoms will most likely need outpatient treatment.
Treatment will focus on:
- managing active symptoms until they go into remission
- maintaining remission to prevent further symptoms
Managing active ulcerative colitis
Treatment will involve the use of several types of medication. We discuss these in the following sections:
5-aminosalicylic acid
This is the standard treatment option for ulcerative colitis. Aminosalicylates tend to be effective in reducing inflammation.
They often come in pill form, but doctors sometimes prescribe them as suppositories. For those who have an allergy to sulfa, there are also sulfa free forms available.
The main forms include:
- Mesalamine
- Balsalazide
- Sulfasalazine
Side effects might include:
- Nausea
- Skin rash
- Headaches
- Diarrhea
Steroids
If the symptoms become severe or do not respond to aminosalicylates, a doctor may prescribe steroids. These can also reduce inflammation.
Prolonged use of steroids, especially oral steroids, can have serious side effects. A doctor will usually recommend discontinuing steroid treatment as soon as the condition responds.
Side effects include:
- Acne and other skin problems
- Low mood
- Sleep problems
- Swelling
- Indigestion
Long term adverse effects include a higher risk of:
- Bruising
- Cataracts
- Diabetes
- Glaucoma
- High blood pressure
- Muscle weakness
- Osteoporosis
- Thinning skin
- Weight gain
- Immunosuppressants
If other treatments have not been effective, or when the gastroenterologist needs to discontinue steroids, immunosuppressants may help relieve symptoms. These reduce immune activity and soothe inflammation in the colon and rectum.
People tend to use an immunosuppressant called azathioprine to treat ulcerative colitis.
Possible side effects include:
- Nausea
- Diarrhea
- Liver damage
- Anemia
- Bruising
- Infections
Biologics
Doctors may prescribe antitumor necrosis factor agents to bring about remission.
These include:
- Infliximab (Remicade)
- Adalimumab (Humira)
- Golimumab (Simponi)
- Vedolizumab (Entyvio), a different biologic that targets the gut mucosal immune system
Xeljanz
Xeljanz is a Janus kinase inhibitor. Studies have shownTrusted Source that it can bring about remission more effectively than corticosteroids.
In 2018, the Food and Drug Administration (FDA) approved 5- and 10-milligram dosesTrusted Source of Xeljanz twice per day for the treatment of this type of ulcerative colitis.
Possible adverse effects include diarrhea, high cholesterol, and shingles. Anyone who experiences adverse effects when taking Xeljanz should speak to their doctor.
Managing severe active ulcerative colitis
Hospitalization will often be necessary due to the risk of malnutrition, dehydration, and life-threatening complications such as colon rupture.
Treatment includes intravenous fluids and medications.
Maintaining remission
As soon as symptoms are in remission, taking regular doses of aminosalicylate can help prevent recurrences. If recurrences occur regularly despite treatment with aminosalicylate, the gastroenterologist may prescribe azathioprine.
People with extensive ulcerative colitis may need long term maintenance therapy. If the person goes into remission for 2 years without a recurrence, the doctor might adjust this course of treatment.
Having a support system with experience and empathy can be vital for helping people cope with ulcerative colitis.
IBD Healthline is a free app for people with the condition. The app is available on the AppStore and Google Play. Download it here.
Surgery
If other treatments do not provide relief, surgery may be an option.
Some surgical options include:
- Colectomy: A surgeon removes part or all of the colon.
- Ileostomy: A surgeon makes an incision in the stomach, extracts the end of the small intestine, and connects it to an external pouch, called a Kock pouch. The pouch then collects waste material from the intestine.
- Ileoanal pouch: A surgeon constructs a pouch from the small intestine and connects it to the muscles surrounding the anus. The ileoanal pouch is not an external pouch.
Frequently Asked Questions about Ulcerative Colitis
What is ulcerative colitis?
Ulcerative colitis is an inflammatory bowel disease of unknown cause in which the gastrointestinal tract is unable to distinguish foreign from self-antigens. It is characterized by chronic inflammation of the colonic mucosa and submucosa, atrophy and possibly dysplasia limited to the colon. The extent of the disease varies and may involve only the rectum (ulcerative proctitis), the left side of the colon to the splenic flexure or the entire colon (pancolitis).
What causes ulcerative colitis?
Hereditary factors seem to play a role in the etiology of ulcerative colitis. The most significant risk factor for the development of ulcerative colitis is a family history. Environmental factors are also involved, as evidenced by higher rates of this disease in urban locales.
What are the symptoms of ulcerative colitis?
The most common symptom of ulcerative colitis is diarrhea that is often bloody. Other symptoms include abdominal and/or rectal pain, fever and weight loss. Some patients complain of constipation and rectal spasm. Arthritis symptoms may occur in as many as 26 percent of patients with ulcerative colitis, dermatological changes in fewer patients and ocular manifestations in about 5 percent.
How is ulcerative colitis diagnosed?
The disease is diagnosed using clinical presentation, CT scans, endoscopy, and usually confirmed by endoscopic biopsy. Because the initial presentation of the disease is indistinguishable from other forms of acute colitis, diagnosis of ulcerative colitis should not be made until all infectious causes are ruled out and symptoms have persisted for at least two weeks. A barium enema is not necessary if all other forms of colitis are excluded and if it is believed that the disease is more than proctosigmoiditis.
Who is affected by ulcerative colitis?
Both sexes are equally affected, and there is a higher prevalence of the disease in Ashkenazi Jews. Heredity does play an important role in this disease. Approximately 10 percent of patients with UC have a first-degree relative with the disease. The peak onset for this disease is the second or third decade of life. A secondary peak is seen in late middle age.
Is there a relationship between smoking cigarettes and developing UC?
Data from population surveys indicate that patients with ulcerative colitis are less likely to be smokers than matched controls from the general population. The relative risk of developing ulcerative colitis among current smokers is about 40 percent.
Former smokers are about 1.7 times more likely to develop the disease than those who have never smoked. Recent controlled trials of nicotine patch therapy for ulcerative colitis suggest that nicotine may play a role in preventing the disease.
There have been anecdotal reports of improvement in active stages when former smokers resumed smoking. However, other forms of medical therapy should be attempted and exhausted before resorting to this method. A high proportion of nonsmokers experienced unacceptable side effects from nicotine patches.
What is the treatment for ulcerative colitis?
The treatment for ulcerative colitis is targeted to active disease and then the maintenance of remission. Medical and surgical modalities are used to treat ulcerative colitis. The majority of patients respond favorably to medical regimens. Surgery is reserved for those patients who are unresponsive to medical therapy and have a severely compromised quality of life.
Will I eventually need to have surgery for ulcerative colitis?
If acute colitis does not respond to intensive medical therapy, surgery may be considered. Patients who have had this disease for eight to 10 years and are steroid-resistant or dependent have an increased risk of colon cancer and should consider colectomy.
What type of surgery is done for ulcerative colitis?
Current surgical alternatives for patients include total proctocolectomy with Brooke ileostomy, intra-abdominal Koch pouch and restorative proctocolectomy with ileal pouch-anal anastomosis. Elective colectomy cures ulcerative colitis and has very low mortality.