Ulcerative Colitis

What Is Ulcerative Colitis? What Causes Ulcerative Colitis?

Ulcerative colitis is a fairly common chronic (long-term) disease that causes inflammation of the colon (the large intestine). It is a form of inflammatory bowel disease that has some similarity to Crohn's disease, a related disorder. The colon - or large intestine - removes nutrients form undigested food and gets rid of waste products through the rectum and anus when we pass feces (stools).

The rectum (end of colon) is always involved in ulcerative colitis. When inflammation is only in the rectum the disease is called ulcerative proctitis. The inflammation may extend into the upper parts of the colon. Universal colitis or pancolitis is when the whole colon is involved.

A condition that causes inflammation of the intestines, such as ulcerative colitis or Crohn's disease is known as IBD (inflammatory bowel disease). IBD is different from IBS (irritable bowel syndrome). Unlike IBD, IBS does not cause inflammation, ulcers or other damage to the bowel. IBS is a much less serious problem, called a functional disorder - the digestive system looks normal but does not work properly.

Ulcerative colitis causes the colon to become inflamed and in severe cases ulcers may form on the lining of the colon. Ulcers are painful sores. The ulcers sometimes bleed and produce pus and mucus.

Approximately 100,000 people in the UK have ulcerative colitis. It usually emerges when the patient is aged between 15 and 30 years. It is more common among people of European ancestry, especially those descended from Jews who lived in Eastern Europe and Russia (Ashkenazi Jews). It is estimated that as many as one million Americans have IBD, with that number evenly split between Crohn's disease and ulcerative colitis. Males and females appear to be affected equally.

What are the symptoms of ulcerative colitis?

The first symptom is a progressive loosening of the feces. The patient may have crampy abdominal pain with a severe urge to have a bowel movement. Diarrhea may begin slowly or suddenly. Symptoms vary according to how much of the colon is affected and how inflamed it is. The most common symptoms include:
  • Abdominal pain
  • Bloody diarrhea with mucus
The following symptoms are also possible:
  • Fatigue (tiredness)
  • Weight loss
  • Loss of appetite
  • Anemia
  • Elevated temperature
  • Dehydration
  • Tenesmus (wanting to empty the bowels constantly)
Most patients report worse symptoms early in the morning.
Many patients with ulcerative colitis may have very mild symptoms or no symptoms at all for long periods (months or years). Unfortunately, without treatment symptoms eventually return.

Below are the signs and symptoms that may accompany ulcerative colitis, depending on how it is classified:
  • Ulcerative proctitis - inflammation is just within the rectum.

    Signs and symptoms include:
    • Rectal bleeding (for some patients this is the only symptom)
    • Rectal pain
    • Feeling of urgency or an inability to move the bowels even though there is an urge to do so.

    Ulcerative proctitis is usually the mildest form of ulcerative colitis.
  • Proctosigmoiditis - this involves the rectum and the sigmoid colon (lower end of the colon).

    Signs and symptoms include:
    • Bloody diarrhea
    • Abdominal cramps
    • Abdominal pain
    • Constant urge to go to the toilet
  • Left-sided colitis - inflammation includes the rectum, up the left side through the sigmoid and descending colon.

    Signs and symptoms include:
    • Bloody diarrhea
    • Abdominal cramping on left side
    • Weight loss
  • Pancolitis - the whole colon is affected.

    Signs and symptoms include:
    • Bloody diarrhea (some bouts may be severe)
    • Abdominal cramps
    • Abdominal pain
    • Fatigue
    • Considerable weight loss
  • Fulminant colitis - a rare form of colitis that can be life-threatening. The whole colon is affected.

    Signs and symptoms include:
    • Severe pain
    • Severe diarrhea, which can lead to dehydration and shock

    Fulminant colitis patients are at risk of colon rupture and toxic megacolon (colon becomes severely distended).

What causes ulcerative colitis?

Experts are not exactly sure what the causes are. Genetics, the environment and the body's own immune system are thought to be involved:
  • Genetics - about one-fifth of all patients with ulcerative colitis have a close relative who has/had the same disease - this indicates that the disease can be inherited. As ulcerative colitis is more prevalent in certain ethnic groups it is likely to have a genetic cause. Recent research has identified a faulty gene that appears to be linked to ulcerative colitis.
  • Environmental - some experts believe that diet, air pollution, cigarette smoke and hygiene may be contributory factors. Ulcerative colitis is more common in urban areas of Western Europe and North America.
  • Immune system - some scientists say that the body responds to a viral or bacterial infection by causing the inflammation linked to ulcerative colitis. However, for some unknown reason, when the infection has gone the immune system continues responding, which carries on causing inflammation. Some scientists disagree and say that the immune system is involved, but there is no infection trigger. They believe the immune system is faulty and fights non-existent infections, causing inflammation - this is known as an autoimmune condition.

What are the risk factors for ulcerative colitis?

A risk factor is something that raises the risk of developing a disease or condition. For example, smoking is a risk factor for lung cancer - it raises the risk of developing lung cancer. Old age is a risk factor for many cancers - the older you are, the higher the risk. Ulcerative colitis affects men and women equally.

Some known risk factors include:
  • Specific ages - although ulcerative colitis can affect people at any age, it more commonly does so to people from the age of 15 to those in their 30s.
  • Ethnicity - ulcerative can affect people of any race or ethnic origin. Caucasian people have a higher risk of developing the diseases, especially those of Ashkenazi Jewish descent (from Eastern Europe and Russia).
  • Genetics - people with a close relative with ulcerative colitis or Crohn's disease have a higher risk of developing the disease.
  • Isotretinoin (Accutane) - this medication is sometimes used for the treatment of scarring cystic acne. It is also used to treat acne that has not responded to other treatments. We are not sure why this powerful medication is a risk factor for ulcerative colitis.
  • NSAIDs (non-steroidal anti-inflammatory drugs) - studies have not specifically shown that NSAIDs cause ulcerative colitis. However, their use can cause similar signs and symptoms. People with ulcerative colitis who take NSAIDs are more likely to have worsening symptoms. Examples of NSAIDs include ibuprofen, naproxen, diclofenac and piroxicam.

How is ulcerative colitis diagnosed?

A GP (general practitioner, primary care physician) will ask the patient about symptoms, their medical history, and try to find out whether any close relatives have/had ulcerative colitis, IBD, or Crohn's disease. The doctor will also examine the patient for signs of anemia (paleness) and tenderness in the abdominal area.

The doctor will try to rule out other possible conditions and diseases, such as Crohn's disease, infection, IBS (irritable bowel syndrome), diverticulitis, colon cancer and ischemic colitis. The following tests may be ordered:
  • Blood tests - a blood test can determine whether the patient has anemia. An ESR (arythrocyte sedimentation rate) test and a CRP (C reactive protein) test can also help determine whether there is inflammation.
  • Stool test - to check whether there is an infection or parasites. If there are white blood cells in the stool it could be an indication of inflammatory disease, which might be ulcerative colitis.
  • X-ray - will help the doctor determine the extent of the condition. A doctor may use an X-ray to rule out toxic megacolon or a perforation.
  • Barium enema - the doctor can evaluate the whole large intestine with an X-ray. Barium is added to the solution in the enema - it is a contrast dye. Sometimes air is added too. The barium coats the lining of the rectum and colon and shows up on the X-ray. This test is performed if a colonoscopy is not possible.
  • Sigmoidoscopy - a sigmoidoscope is a flexible tube with a camera at the end. It is inserted via the anus into the rectum. The doctor sees images of the rectum and lower part of the colon on a monitor. In order to check further up the digestive system a colonoscopy will be required.
  • Colonoscopy - the doctor uses a colonoscope, a long, flexible viewing tube with a camera at the end. It is inserted via the anus through the rectum. The doctor can inspect the entire colon and rectum. If any abnormality is detected the doctor may take a biopsy or remove it. For a colonoscopy procedure the colon will need to be entirely emptied.
  • A CT (computed tomography) scan - a scan of the abdomen or pelvis may be performed if the doctor wants to find out whether the patient has Crohn's disease.

What are the treatment options for ulcerative colitis?

If the GP confirms a diagnosis of ulcerative colitis the patient will be referred to a gastroenterologist (a doctor who specializes in diseases, conditions, and treatments of the digestive system). The specialist will assess the severity of the condition and devise a treatment plant.

The following factors will contribute towards deciding how severe the condition is:
  • How often the patient is passing stools
  • Whether the stools are bloody
  • The patient's body temperature
  • The patient's bladder control
  • The patient's general state of health
Patients with severe symptoms will usually have to be hospitalized, while those with mild to moderate symptoms are most likely to be treated on an out-patient-basis.

Treatment will focus on:
  • Managing active ulcerative colitis - treating current symptoms until they go into remission.
  • Maintaining remission - treating the patient on remission to prevent recurrence of symptoms.
Managing active ulcerative colitis - treatment will involve the use of three main types of medications:
  • Aminosalicylates - this is the first treatment option for patients with mild to moderate ulcerative colitis. Aminosalicylates are usually effective in reducing inflammation. They can be swallowed in tablet form, may be rubbed on to the affected areas as a cream (topical medication), inserted into the rectum (suppository medication), or added to a fluid and pumped into the colon via the anus (enema medication).

    Patients with mild symptoms are usually given oral tablets or topical aminosalicylates. Those with more serious forms of ulcerative colitis, where the entire colon is affected may require an enema.

    Side effects include:
  • Steroids - patients with more severe ulcerative colitis, or those who did not respond to aminosalicylates may be prescribed steroids, which also reduce inflammation. Steroids are much stronger than aminosalicylates. Patients may be given steroids as oral, suppository, enema or topical medications.

    Long-term steroid use, especially oral steroids, can have serious side-effects. As soon as the patient responds to treatment the steroids will usually be discontinued.

    Side effects include:
    • Acne, and other skin problems
    • Moodiness
    • Sleep problems
    • Swelling
    • Indigestion

    Side effects after more than 12 weeks use:

    Patients taking steroids should make sure they have plenty of calcium in their diet, try not to gain weight, not smoke, do regular physical exercise, and make sure their alcohol intake is kept within recommended limits.

    Any patient on long-term steroids needs close monitoring for blood pressure, diabetes and osteoporosis.
  • Immunosuppressants - individuals who do not respond to treatment, or those whose steroid prescription has been discontinued, may be prescribed immunosuppressants. Immunosuppressants lower the patient's immune system, which usually reduces inflammation in the colon/rectum.

    Immunosuppressants usually take a few months to become effective.

    Immunosuppressants will affect the whole body's immune system, making the patient more susceptible to infection. It is important to monitor the patient closely for signs and symptoms of infection.

    Immunosuppressants also raise the risk of developing anemia. Patients will need to have regular blood tests.

    Azathioprine is a commonly used immunosuppressant for patients with ulcerative colitis.

    Possible side effects include:
    • Nausea
    • Diarrhea
    • Liver damage
    • Anemia
    • Bruising
    • Infections

    Patients receiving azathioprine for a long time have a slightly increased risk of developing skin cancer, and some other cancers. They should avoid exposure to strong sunlight.
Managing severe active ulcerative colitis - the patient will need to be hospitalized because there is a risk of malnutrition, dehydration and some life-threatening complications, such as colon rupture. The patient will receive intravenous fluids, as well as the necessary medications.

Maintaining remission - as soon as symptoms are in remission the patient will take regular doses of aminosalicylates to prevent recurrences.

If recurrences regularly occur, despite aminosalicylate treatment, azathioprinethe may be prescribed.

Patients with extensive ulcerative colitis may require long-term maintenance therapy. This therapy may be altered if they go into remission for two years without a recurrence.

Surgery - if treatments do not work the patient may have to consider surgery.
  • Colectomy - the colon, or part of it is removed. The small intestine will have to be rerouted from the colon so that waste products can pass out of the body.
  • Ileo-anal pouch, or ileostomy - The use of an ileostomy has recently been replaced by an ileo-anal pouch. An ileostomy requires an incision in the stomach - the small intestine is then pulled out of the hole and connected to an external pouch. The pouch collects waste material from the intestine. The ileo-anal pouch is constructed by the surgeon internally, out of the small intestine and then connected to the muscles surrounding the anus. The pouch is then emptied in a similar way to when we go to the toilet and have a bowel movement. The ileo-anal pouch is not an external pouch.
  • Nicotine patches - nicotine appears to relieve some of the symptoms of ulcerative colitis. However, conventional medications are more effective.

What are the possible complications of ulcerative colitis?

  • Colorectal cancer - ulcerative colitis patients, especially those whose symptoms are severe or extensive, have a higher risk of developing colon cancer. People who have had ulcerative colitis for ten years have a 2% higher risk than others, after 20 years the risk increases to 8%, and after 30 years to 18%.

    Patients commonly undergo a colonoscopy to check for colon cancer. The frequency of these check ups increases as the years pass.
  • Toxic megacolon - this complication affects approximately 5% of patients with severe ulcerative colitis. In severe cases gas becomes trapped, causing the colon to swell. When this happens there is a risk of colon rupture, septicemia, and the patient's body can go into shock.
  • Other possible complications include:

    • Inflammation of the skin
    • Inflammation of the joints
    • Inflammation of the eyes
    • Liver disease
    • Osteoporosis
    • Perforated colon
    • Severe bleeding
    • Severe dehydration


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