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).
Ulcerative colitis causes the colon to become inflamed and, in severe cases, ulcers (painful sores) may form on the lining of the colon. The ulcers sometimes bleed and produce pus and mucus.
According to the journal American Family Physician, ulcerative colitis affects between 250,000 and 500,000 people in the United States, with an annual incidence of 2-7 per 100,000 persons.
The rectum (end of the colon) is always involved in ulcerative colitis. If the inflammation is only in the rectum, the disease is called ulcerative proctitis. However, the inflammation can extend into the upper parts of the colon. Universal colitis, or pancolitis, is when the whole colon is affected.
Symptoms of ulcerative colitis
Abdominal pain is a common symptom of ulcerative colitis.
The first symptom is a progressive loosening of the feces - diarrhea. 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
- elevated temperature
- tenesmus (feeling the urge 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.
Signs and symptoms vary depending on which part of the bowel is affected:
Inflammation is just within the rectum. Signs and symptoms include:
- rectal bleeding (for some patients this is the only symptom)
- rectal pain
- 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.
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
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
The whole colon is affected. Signs and symptoms include:
- bloody diarrhea (some bouts may be severe)
- abdominal cramps
- abdominal pain
- considerable weight loss
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).
Causes of ulcerative colitis
Experts are not exactly sure what causes ulcerative colitis. 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 or had the same disease; this indicates that the disease can be inherited.
Environmental - some experts believe that diet, air pollution, cigarette smoke, and hygiene may be contributory factors.
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 immune system is faulty and fights non-existent infections, causing inflammation - this is known as an autoimmune condition.
High intake of linoleic acid - one study found that one third of all ulcerative colitis cases are linked to a high intake of linoleic acid, a common fatty acid. It can be found in red meat, several cooking oils, and some types of margarine.
What are the risk factors for ulcerative colitis?
Some known risk factors include:
Age - although ulcerative colitis can affect people at any age, it more commonly affects 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 disease, 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.
Difference between IBS and IBD
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.
How is ulcerative colitis diagnosed?
Before diagnosing ulcerative colitis, other conditions must be ruled out.
A doctor 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 first try to rule out other possible conditions and diseases, such as Crohn's disease, infection, IBS, diverticulitis, colon cancer, and ischemic colitis. The following tests may be ordered:
- Blood tests.
- Stool tests.
- Barium enema.
- Sigmoidoscopy - a sigmoidoscope is a flexible tube with a camera at the end. It is inserted via the anus into the rectum.
- 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. It can travel farther than a sigmoidoscope.
- A CT (computed tomography) scan - a scan of the abdomen or pelvis.
Treatment options for ulcerative colitis
If a doctor diagnoses 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 create a treatment plant.
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.
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:
- skin rash
Steroids - patients with more severe ulcerative colitis, or those who did not respond to aminosalicylates may be prescribed steroids, which also reduce inflammation.
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 weaned off and discontinued.
Side effects include:
- acne, and other skin problems
- sleep problems
Side effects after more than 12 weeks of use:
- hypertension (high blood pressure)
- muscle weakness
- thinning of the skin
- weight gain
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.
Azathioprine is a commonly used immunosuppressant for patients with ulcerative colitis.
Possible side effects include:
- liver damage
Infliximab (Remicade) - this may be prescribed for patients with moderate to severe symptoms who did not respond to other treatments or could not tolerate them. Infliximab is said to work rapidly at bringing on remission, especially if corticosteroids did not help. In some cases, it can even prevent the need for surgery.
Managing severe active ulcerative colitis
The patient will need to be hospitalized because there is a risk of malnutrition, dehydration, and life-threatening complications, such as colon rupture. The patient will receive intravenous fluids, as well as medications.
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, azathioprine 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 2 years without a recurrence.
If treatments do not work, the patient may have to consider surgery.
Colectomy - the colon, or part of it, is removed.
Ileostomy - this 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.
Ileo-anal pouch - the pouch is constructed by the surgeon internally, out of the small intestine, and then connected to the muscles surrounding the anus. The ileo-anal pouch is not an external pouch.
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. According to the National Institutes of Health, colon cancer risk is higher when the entire colon is affected for a long period.
Toxic megacolon - this complication affects a small number 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
- perforated colon
- severe bleeding
- severe dehydration