What is Ulcerative Colitis?
Ulcerative colitis (UC) is a chronic disorder of the gastrointestinal (GI) tract and is one of the disorders in the group called inflammatory bowel diseases (IBD). It causes inflammation of the tissue of the GI tract, typically in the rectum and lower colon, but it can extend through the entire colon. It often leads to rectal bleeding and diarrhea.
Why does it happen?
The cause of ulcerative colitis is unknown at this point, but researchers are working hard to determine why this occurs. We do know that nothing YOU did made you develop UC and you did not catch it from something. The disorder involves the body’s immune system acting inappropriately from its usual function of working to protect the body from infection. What causes this abnormal response may be related to specific genes a person has, or something in the environment that causes the immune system to be activated when it does not need to be. Ultimately, because the immune system is “turned on” and ready to fight, it can cause inflammation and actually damage the lining of the GI tract leading to symptoms.
What are the symptoms?
The symptoms can be variable and may change over time. The inflammation in the colon only affects the mucosal lining; it typically involves the rectum and then may move toward the other portions of the colon. Symptoms of UC can include:
- Rectal bleeding
- Mucus discharge from the rectum
- Crampy abdominal pain
- Straining with bowel movements and constipation
- Fever. This can be due to inflammation or active infection.
- Loss of appetite.
- Weight loss. This can be related to lack of appetite, decreased absorption of nutrients, or
- chronic diarrhea.
Interestingly, the disease doesn’t only affect the GI tract and can cause problems outside this system such as in the joints, liver, eyes, skin, and lungs.
How is it diagnosed?
There is not one test or exam finding to diagnose UC, rather it is determined based on a combination of findings. Usually symptoms start gradually. Typically, some or all of the below will be used:
- History of symptoms concerning for UC with physical examination.
- Laboratory studies may be obtained to look at blood counts, electrolytes, markers of inflammation, liver function, kidney function, and stool studies. A blood test may be ordered that measures antibody levels that help determine the difference between ulcerative colitis and Crohn’s disease.
- Colonoscopy to look at the tissue of the colon and last part of the small intestine, the terminal ileum. Sample of the tissue (biopsies) can be taken to be examined with a microscope.
- Imaging studies may be obtained including barium studies with an enema or small bowel follow through or possibly a computed tomography (CT) or magnetic resonance imaging (MRI)
How is it treated?
Typically, UC is made up of periods where the disease worsens and times where you have no symptoms at all. Medicines are used to treat symptoms decreasing inflammation and activity of the immune system so the tissue of the GI tract can heal. The goal of treatment is to “induce remission,” meaning getting symptoms under control and then decrease the frequency of symptoms, recur or “maintaining remission”. There are multiple types of drugs used to treat ulcerative colitis. The choice of what medicine to use is dependent on the location of disease activity, the intensity of inflammation, and the goal of treatment.
If the inflammation is limited to just your rectum or end of your colon, most people do well. 20% resolve on their own and most others are in remission with drug therapy, but in up to 15% of people, within 5 years the disease progresses to involve more of the colon.
If the disease if more extensive, while medications still can be effective, remission is less likely. Once in remission, there is no increased risk of symptom flares. If medical therapy is not working or if there are complications, surgery may be necessary.
Treatment options include
Preparations in a suppository or enema form are especially effective in people with disease limited to the end of their colon.
Sulfasalazine (Azulfidine); olsalazine (Dipentum); balsalazide (Colazal); mesalamine (Oral: Apriso, Asacol, Asacol HD, Lialda, Pentasa; Rectal suppository or enema: Canasa, Rowasa)
Sulfasalzine is thought to act locally right at the lining of the GI tract in the colon to decrease inflammation. Olsalazine and balsalazide are converted to mesalamine, the active component of sulfasalazine, in the colon. The specific mechanism of mesalamine is unknown but is it thought that it decreases the local inflammatory response directly at the irritated tissue.
These can be put into the rectum to get right to the site of inflammation as a suppository or foam, can be given orally, or, if severe symptoms, through an intravenous (IV) line. Steroids suppress the immune system throughout the body. This will stop the immune system from attacking the intestinal tissue. They are often effective, but also associated with many side effects because it works widely throughout the body. This medicine is not for long term use. Budesonide is a steroid available that does not act throughout the whole body, but rather more specifically to the ileum and right colon.
Azathioprine and 6-mercaptopurine (6-MP)
6-MP is the active metabolite of azathioprine. These medicines suppress the immune response so it cannot continue to cause active inflammation.
Such as loperamide (Imodium) or a bile binder like cholestyramine or colstipol can be used for symptomatic relief. If you are acutely ill, do NOT use these as they can increase the risk of toxic megacolon which can lead to perforation of the colon.
Cyclosporine is a medicine that can be given by mouth or through an IV if disease is significant and not responding to other therapies. It works by suppressing the immune system. Side effects are common with this medicine so careful monitoring is essential.
Tumor necrosis factor-alpha (TNF-alpha) is a chemical the immune system produces to make inflammation more intense. These therapies block the action of TNF-alpha.
- Inflixamab (Remicade) chimeric monoclonal antibody- hybrid of 75% human, 25% murine (mouse) antibody. It is given through IV infusion.
- Adalimumab (Humira) is a man-made protein. It is given as an injection. The first injections are given in a physician office, either four on one day or two given for two days, then two injections two weeks later. This completes the “induction” period and then only one injection is needed every other week.
- Nataliumab (Tysabri)
An antibody that is given by infusion, thought to block certain white blood cells involved in creating inflammation
- Certolizumab pegol (Cimzia)
Another TNF-alpha antibody. It will bind to that protein and block its effects. It is given by injection every two weeks for the first three injections and then usually once every four weeks.
Sometimes medicine does not do enough to treat UC and surgery is necessary. Surgery can be curative.
What can I do?
Ulcerative colitis often goes between periods of increased disease activity with symptoms and periods
of remission. 15% of people will have an initial attack, but then stay in remission, even without
medications, sometimes for the rest of their lives.
Often people are concerned with what type of diet they should be on once diagnosed with UC. There are no specific foods that will cause increased inflammation in the GI tract; however, certain foods may cause more symptoms for you. Good nutrition is key as nutritional deficiencies are possible because of poor absorption, chronic diarrhea, decreased appetite, and increased energy needs of the body because of the chronic disease. Generally soft, bland foods may be easier to consume than spicy or high fiber foods.
Regular exercise is important.
Avoid nonsteoridal anti-inflammatory drugs, (ex. Ibuprofen or naprosyn) because these can worsen disease.
Are there complications?
Because of the active inflammation:
- Severe bleeding can occur (3%)
- Severe inflammation that goes deeper than just the surface layer of the tissue can change the motility of the colon allowing the wall to distend eventually leading to “toxic megacolon” which eventually can lead to perforation
- With repeated inflammation and sometimes increased size of muscles, strictures, narrowing of the gut wall which can cause obstruction can form (10%)
- There is increased risk of developing colon cancer. This is related to how severe your disease is and how long you have had it.
Interestingly, as stated before, the disease may not only affect the GI tract and problems outside
this system can also occur such as:
- Arthritis, usually in large joints
- Eye problems including uveitis and episcleritis( redness, pain, itchiness)
- Skin disorders such as erythema nodosum (a red nodular rash on the shins) and pyoderma gangrenosum (large painful sores form, mainly on the legs)
- Primary sclerosing cholangitis (inflammation and scarring of the bile ducts in the liver)
- Cholangiocarcinoma (cancer in the bile ducts in the liver)
- Lung disease
- Blood clots in arteries or veins
For more information on Ulcerative Colitis, call our Gastroenterology offices at (715) 847-2558.
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