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Definition
Ulcerative colitis is a disease of unknown cause, which is characterized by recurring episodes of inflammation involving the surface lining of the colon. The inflammation almost always involves the rectum and extends in continuous fashion to involve more proximal portions of the colon.
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Causes and Risk Factors
The cause of ulcerative colitis remains unknown. There may be several factors at play. The current thinking is that there may be genetic and environmental factors that provoke an alteration in the way the body’s immune system works.
Genetics: A number of observations suggest that genetically determined factors may contribute to ulcerative colitis. However, the data are weak and no specific genetic pattern of inheritance has been identified.
Immune System: In the process of carrying out the absorption of nutrients, the intestine must discriminate between innocuous food substances and potentially harmful infectious or toxic agents. The immune system serves as a protective barrier to harmful agents. Several studies suggest that ulcerative colitis may be associated with an abnormal immune system. The relationship between immune defects and the development of ulcerative colitis is not certain. It is clear, however, that drugs which suppress the immune system have benefit to patients with ulcerative colitis.
Diet: No studies have directly identified a specific dietary factor that is either absent, or present in excess, in patients with ulcerative colitis.
Psychosocial Factors: There is no evidence that emotional disturbances cause ulcerative colitis. However, any chronic illness can be stressful and cause anxiety. Furthermore, anxiety and stress in ones personal life can make coping with illness that much more difficult, and may even cause symptoms to worsen.
Oral Contraceptives: Some studies have suggested a correlation between oral contraceptive use and ulcerative colitis. Other studies have contradicted this finding.
Nonsteroidal Anti-inflammatory Drugs (NSAIDs): There is some evidence that some arthritis drugs such as aspirin, ibuprofen (Motrin, Advil), indomethecin (Indocin), and naproxen (Aleve, Naprosyn) may exacerbate ulcerative colitis. The newer cox-2 inhibitors (Celebrex), while safer for the stomach, may still provoke a flare of ulcerative colitis.
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Symptoms
Patients usually present between ages 15 and 40. The first symptoms are usually a tendency toward more frequent, urgent, loose, small volume stools with blood and mucous. The pattern is usually one of periods of complete symptomatic remission alternating with periods of symptom relapse. With more severe cases there can be abdominal crampy pain, fever, diminished appetite, anemia, and malnutrition. Massive bleeding and fulminant colitis are rare complications. There are occasional patients for whom remission cannot be achieved with medical therapy.
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Diagnosis
Diagnosis is usually made by the typical appearance of the lining of the rectum and colon as seen on sigmoidoscopy or colonoscopy in a patient with the characteristic symptom complex. Since the cause of ulcerative colitis is unknown, and the characteristic pattern of illness involves periods of exacerbation and remission, definitive diagnosis sometimes requires observation over time.
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Cancer of the Colon and Ulcerative Colitis
Persons with chronic ulcerative colitis are at increased risk for the development of colon cancer. The risk is related to the length of time that has elapsed since initial diagnosis, and the extent of involvement. It is not related to the severity of symptoms. Fortunately, with screening colonoscopy, most cancers can be prevented or diagnosed very early with a high cure rate. Colonoscopy should be done every 1 to 2 years after 8 years of total colitis or 12 to 15 years of left sided colitis. By doing colonoscopy and biopsy on a regular basis, warning changes (dysplasia) can usually be identified prior to the development of cancer. In these cases, preventive surgery is recommended.
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Extraintestinal Manifestations
Ulcerative colitis can be associated with a number of non-intestinal problems, some of which are listed below. It is important that your gastroenterologist be notified if you develop any other medical problem, and any other physicians you see should be aware that you have ulcerative colitis. With the exceptions of ankylosing spondylitis and sclerosing cholangitis, which usually run their own course, aggressive treatment of the colitis often results in improvement of the extraintestinal manifestations.
Erythema Nodosum: tender red bumps that often occur over the shins or ankles.
Pyoderma Gangrenosa: chronic ulcers that occur on the shins or ankles.
Apthous Stomatitis: canker sores that occur in the mouth.
Arthritis: small joints of the hands and feet can be involved.
Ankylosing Spondylitis: arthritis of the spine.
Uveitis: a painful inflammation of the eye.
Sclerosing Cholangitis: inflammation in the bile ducts, which can result in jaundice.
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Medical Treatment
There are several types of treatment available, and most patients respond well and go about their lives with few interruptions. Occasionally, some attacks may be more severe requiring periods of bowel rest, intravenous treatment, and hospitalization.
Corticosteroids: Corticosteroids are a class of medications which are similar to chemicals made by the one’s own adrenal gland. They can be given topically in enema form (Cortenema), orally (prednisone), or intravenously (hydrocortisone or prednisolone). These are highly effective drugs which often bring symptoms under control within a couple of weeks. Unfortunately, they have many side effects which include (but are not limited to) water retention and weight gain, bone thinning, acne, mood alterations, sleep disturbance, muscle weakness, cataracts, and increased susceptibility to certain types of infections. Side effects are usually related to the dose and the length of time on the drug, and can usually be managed by reducing the dose. A high dose (40 to 60 mg. of prednisone) is often used initially to bring the symptoms under control. The dose is then reduced at a rate which is determined by the presence of side effects and any persistent symptoms.
5 ASA products: Sulfasalazine (Azulfidine), olsalazine (Dipentum), and mesalamine (Pentasa and Asacol) can be very effective in treating mild symptoms and are used as an adjunct to therapy with prednisone in patients with more severe symptoms. Mesalamine applied topically in enema form (Rowasa) has been shown to be 90% effective in inducing remission when the colitis is limited to the left side of the colon. These drugs can be very important to take when feeling well since they have been shown to prolong periods of remission. They have very few side effects and are also safe to take during pregnancy. Sulfasalazine can cause a reversible reduction in sperm count in men, and should be given with folic acid (a vitamin). Occasionally, at high doses, they can cause headaches or upset stomach. They should be avoided by patients who have allergy to aspirin.
Azothioprine (Imuran) and 6- Mercaptopurine (Purinethol): For those whose symptoms remain troublesome despite intensive therapy with prednisone and mesalamine, these immune suppressing drugs may be helpful. After 3 to 6 months of therapy, they may allow a reduction in the dose of prednisone. However, since surgery is curative, many physicians are reluctant to begin long term therapy with potentially toxic drugs.
Cyclosporine: Cyclosporine suppresses the immune system and has been shown to be effective in severely ill patients who do not respond to corticostreroids. Therapy is usually initiated in the hospital. It can allow surgery to be avoided in severely ill patients, but the long term benefit is not clear.
Nicotine: Nicotine therapy may be of benefit to a limited number of patients with refractory ulcerative colitis. However, the use of nicotine patches in nonsmokers has been associated with considerable side effects.
Fish Oil: One study showed benefit from a four month course of eicoapentaenoic acid (EPA) derived from fish oil. However, this therapy requires about 18 capsules per day and causes a fishy odor in the breath.
Nutritional Considerations: Although dietary factors have not been implicated in the cause of ulcerative colitis, food intolerances may occur. More importantly, chronic illness, poor appetite, chronic blood loss, and intestinal dysfunction can lead to malnutrition. Therefore it is very important to discuss with your doctor the best way to balance nutritional needs with specific food intolerances which may occur. Specific vitamin and mineral supplementation may be warranted. In patients with abdominal pain and diarrhea it may be advisable to avoid raw fruits and vegetables, caffeine, carbonated drinks, and sorbitol containing diet foods. If there is a lactose intolerance, milk should be avoided and a calcium supplement taken. If there is frequent bleeding, iron supplementation may be needed.
Psychosocial Considerations: Coping with chronic illness can be very stressful. For some patients, support groups organized by the Crohn’s & Colitis Foundation of America (CCFA) can be helpful. Generally medications are not needed for psychologic distress associated with a flare of colitis. However, some individuals may experience greater difficulties with anxiety or depression and benefit from medication.
Constipating agents: Medications such as loperimide (Imodium) and lomotil may be helpful for patients with mild disease, but can be hazardous for those with severe involvement.
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Surgery
Surgical removal of the colon can be curative for ulcerative colitis. Emergency indications include severe bleeding and toxic megacolon. Elective indications include chronic severe symptoms, failure of medical therapy, and high risk of colon cancer. The most common operation is a proctocolectomy with an ileoanal pouch anastomosis. It is usually done in two stages. The first is removal of the colon and rectum and creation of a pouch using a portion of the small intestine. This pouch serves as a new rectum and is attached to the anus. The pouch is allowed to heal by constructing a temporary ileostomy to prevent stool from passing into the healing pouch. Six to eight weeks later, in a relatively minor operation, the ileostomy is removed, allowing the patient to have normal bowel movements through the anus. After the operations, patients average 6 or 7 bowel movements per day.
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Pregnancy and Ulcerative Colitis
Most studies show that ulcerative colitis has no influence on pregnancy outcomes in terms of preterm delivery rate, birth weight, spontaneous abortion, or malformations. Women with ulcerative colitis in remission at the time of conception have normal and healthy babies in the same proportion as women without colitis. If conception occurs during a flare up, however, spontaneous abortions and premature delivery are slightly more common. Therefore it is generally a good idea for a woman to delay pregnancy until in remission.
Prednisone, sulfasalazine, and 5-ASA compounds (Dipentum, Asacol, Pentasa) are safe during pregnancy. In fact, drugs such as the 5-ASA compounds, which can prevent relapse, should generally be continued during pregnancy since a flare of the disease is more hazardous than the medications. On the other hand, immunosuppressive drugs such as cyclosporine, azothioprine, and 6-mercaptopurine may cause genetic damage and should be avoided if pregnancy is anticipated. If the male partner is taking sulfasalazine (Azulfidine) for ulcerative colitis, there may be a temporary and reversible reduction in sperm count.
For more information on ulcerative colitis, contact Crohn’s & Colitis Foundation of America (CCFA).
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