Ulcerative Colitis

Other name: Inflammatory Bowel Disease
The term "colitis" is a general term, and can apply to infections and any other condition associated with an inflamed colonic lining.

Ulcerative colitis (UC) is one form of inflammatory bowel disease (IBD); Crohn's disease is another. Ulcerative colitis is distinct from Crohn's disease although in some patients it can be difficult to tell the difference, particularly in the early stages. Since the treatment is often the same for both conditions in the early stages it may not be essential to reach a final diagnosis at that time.

In ulcerative colitis, the inner lining of the large intestine (colon or bowel) and rectum becomes inflamed. The small intestine is not involved.

The inflammation may involve: the rectum alone (proctitis); the rectum and sigmoid colon (proctosigmoiditis or distal colitis); the rectum and a large part of the colon (sub-total colitis); or the rectum and the entire colon (total or universal colitis). These are descriptive terms - it is the same disease process although for reasons that are not understood, the disease may remain confined to one part of the colon.

Frequency in the Community

Ulcerative colitis affects all age groups but tends to be more common in young people (e.g. ages 15-40). It affects males and females equally and appears to run in some families.

Cause of Ulcerative Colitis

The cause of ulcerative colitis is not known.

There may be an interaction between environmental, genetic, immunological factors, and infectious agents (viruses or bacteria). There is no evidence that a particular diet causes ulcerative colitis, but unidentified dietary factors may make the disease worse. Psychological stress does not cause ulcerative colitis, but may make the symptoms worse. Cigarette smokers have about half the risk of developing ulcerative colitis as non-smokers, and the disease is likely to be more severe if a smoker has recently ceased smoking. In contrast, smokers are twice as likely as non-smokers to develop Crohn's disease.

Symptoms

The most common symptoms of ulcerative colitis are abdominal pain and diarrhoea, which may contain blood, mucous and pus. Patients may suffer fatigue, weight loss, appetite loss, dehydration and malnutrition. Severe bleeding can lead to anaemia. Occasionally patients develop mouth ulcers, skin problems, joint or back pains, inflammation of the eyes, or liver disorders.

Diagnosis

The diagnosis of ulcerative colitis is made by looking at the lining of the bowel (colon). This is done by passing a flexible tube (endoscope) into the rectum and colon through the anus. A full colonoscopy (see Gastrointestinal Investigations) may be done but the diagnosis can be made on a more limited examination. During the examination, a sample of tissue (biopsy) will be taken from the lining of the colon to view under the microscope.

Colonoscopy or flexible sigmoidoscopy is the preferred method of diagnosis; very rarely a barium enema examination is done.

Other useful investigations include blood tests to see if you are anaemic (as a result of blood loss), or if your white blood cell count is elevated (a sign of inflammation). Kidney and liver function tests will be done, and examination of a stool sample to see if an infection is causing the colitis.

Medical Treatment

The patient should be offered emotional and psychological support. It may be helpful to join a support group, such as the Crohn's and Colitis Association. There is no special diet for ulcerative colitis, although patients may find it necessary to avoid certain foods (e.g. highly seasoned foods or dairy foods) which worsen their symptoms.

There are 4 classes of medications which are useful in inflammatory bowel disease:

- Corticosteroids

- Mesalazine-delivering drugs

- Immunomodulators

- Antibiotics

Patients with ulcerative colitis occasionally have symptoms severe enough to require admission to hospital. This allows the bowel to be rested by limiting oral intake, the use of intravenous fluids and medications, intravenous feeding, correction of dehydration, and close observation for possible complications.

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Other Treatment

Most people with ulcerative colitis will never need to have surgery. However, a small proportion of patients eventually require surgery for removal of the colon because of chronic debilitating illness not responding to treatment, massive bleeding, perforation of the colon, or risk of cancer.

There are several surgical options, each of which has advantages and disadvantages. The surgeon and patient must decide on the best individual option. The most common operation is removal of the entire colon and rectum (proctocolectomy), with ileostomy. Ileostomy is the creation of a small opening in the abdominal wall where the lower small intestine (ileum) is brought to the skin's surface to allow drainage of waste. A special appliance is worn over the opening to collect waste and the patient empties this several times each day.

Proctocolectomy with continent ileostomy is an alternative to standard ileostomy. In this operation, the surgeon creates a pouch out of the ileum inside the wall of the lower abdomen. The patient is able to empty the pouch by inserting a tube through a small leak-proof opening in his or her side. Creation of this natural valve eliminates the need for an external appliance. However, the patient must wear an external pouch for the first few months after the operation.

Another operation that avoids the use of a pouch is ileoanal anastomosis. The diseased portion of the colon is removed and the outer muscles of the rectum are preserved. The surgeon attaches the lower small intestine (ileum) inside the rectum, forming a pouch, or reservoir, that holds the waste. This allows the patient to pass stool through the anus in a normal manner, although the bowel movements are usually more frequent and watery.

In addition to receiving advice from your gastroenterologist and surgeon, you may wish to talk to another patient who has been through surgery for ulcerative colitis. You can contact patients and obtain more information on ulcerative colitis and ileostomies from patient support organisations (see links below).

What to expect

Most patients respond to treatment over a period of a few weeks or months and will eventually be left with only mild bowel symptoms. Some patients have relapses and remissions. A small proportion suffer severe continuous symptoms that respond poorly to treatment, requiring larger doses of medication, or more complex medical treatments. Only in rare cases, when complications occur, is surgery required, and the disease is now very rarely fatal.

Prevention

The risk of colon cancer is greater than normal in patients with widespread ulcerative colitis, especially if the colitis has been present for many years. Your doctor will advise regular colonoscopy examinations, the frequency depending on the duration of the disease and other factors. At the time of colonoscopy biopsies are taken for pathological examination. A pre-cancerous change may occur in the cells lining the colon - these changes are called ‘dysplasia’. If your biopsies show dysplasia your doctor will advise close follow-up and possibly surgery to remove the colon and eliminate the risk of colon cancer.