Ulcerative colitis is a type of inflammatory bowel disease (IBD). As the name implies, IBD is characterised by chronic intestinal inflammation particularly, swelling due to cellular processes. The other major IBD is Crohn’s disease.
Introduction
Ulcerative colitis is a disease that is characterised by inflammation and micro-ulcers in the superficial layers of the large intestine. The inflammation usually occurs in the rectum and lower part of the colon, but in some cases may affect the entire large intestine (pancolitis). Ulcerative colitis can very rarely affect the small intestine in its distal portion (terminal ileitis).
The inflammation is usually accompanied with diarrhoea, which may be profuse and bloody. Micro-ulcers form in places where inflammation has destroyed the cells lining the bowel and these areas bleed producing both pus and mucus.
Ulcerative colitis occurs most often in people aged 15 to 30, although the disease may afflict people of any age. It affects men and women equally and appears to run in some families. Unlike Crohn’s disease, cigarette smoking appears to decrease the risk of developing ulcerative colitis.
Causes and Symptoms
The cause of ulcerative colitis is unknown. There is some evidence to suggest that the body’s immune system reacts to an environmental, dietary or infectious agent in genetically susceptible individuals causing inflammation in the intestinal wall. The postulated causal agent is said to be an infection of the lining with a bacteria, Fusobacterium varium identified by researchers from Japan. Ulcerative colitis is not caused by emotional distress or sensitivity to certain foods or food products, but these factors may trigger symptoms in some people. Ulcerative colitis is most likely not an aberrant reaction but an infection.
The most common symptoms of ulcerative colitis are bloody diarrhoea and abdominal pain. Patients may also experience fever, rectal bleeding, fatigue, anaemia, loss of appetite, weight loss and loss of body fluids and nutrients resulting in nutritional deficiencies. There are episodes of flare-ups when symptoms occur, followed by periods of remissions when there are no symptoms. These disease-free periods can last for months or even years. Usually an attack begins with increased urgency to defecate, mild lower abdominal cramps and blood and/or mucus in the stool.
Ulcerative colitis may cause long-term problems such as arthritis, inflammation of the eye, liver disease (fatty liver, hepatitis, cirrhosis, and primary sclerosing cholangitis), osteoporosis, skin rashes, anaemia and kidney stones. These complications may occur when the immune system triggers inflammation in other parts of the body. These problems resolve when the colitis is treated effectively.
Diagnosis
Ulcerative colitis can be difficult to diagnose because symptoms are similar to other intestinal disorders, most notably Crohn’s disease and irritable bowel syndrome. Ulcerative colitis differs from Crohn’s disease in that the inflammation is confined to the upper layers of the intestinal lining, whereas Crohn’s causes inflammation through the whole thickness of the intestinal wall. Crohn’s disease usually occurs in the small intestine, but it can also occur in the large intestine, anus, oesophagus, stomach, appendix and mouth. Crohn’s disease causes fistulae whereas ulcerative colitis does not. Both Crohn’s and ulcerative colitis may co-exist in the same patient.
A thorough physical exam and a series of tests may be required to diagnose ulcerative colitis. Blood tests may be performed to check for anaemia, which could indicate bleeding in the colon or rectum. Blood tests may also uncover a high white blood cell count, which is a sign of inflammation or infection. By testing a stool sample, the doctor can tell if there is a specific bacterial, parasitic infection or bleeding in the intestine.
If ulcerative colitis is suspected a colonoscopy may be required to confirm the diagnosis. For this test, the gastroenterologist inserts an endoscope, a long, flexible, tube equipped with a miniature camera and fibre optics into the anus to view the inside of the colon and rectum. Inflammation, bleeding, or ulcers on the colon wall can be visualised. The gastroenterologist may take a biopsy, which is a sample of tissue from the lining of the colon, to examine under a microscope. A barium enema x-ray of the colon may also be required. This procedure involves the patient swallowing barium, a chalky, white solution. The barium being absorptive of radiation shows up on x-ray film and allows ulcers or other abnormalities to be seen.
Treatment
Treatment for ulcerative colitis depends on the severity of the disease. Most people are treated with medication. However, some people whose symptoms are triggered by certain foods are able to control their symptoms by avoiding foods that upset their intestines, like highly seasoned foods or dairy products. Each person experiences ulcerative colitis differently, so treatment is adjusted for each individual. Emotional and psychological support is also important. Patients with ulcerative colitis may need medical care for some time, with regular visits to the doctor to monitor the condition.
Drug Therapy
Anti-inflammatory agents
The class of drugs known as aminosalicylates (5-ASA) are used to treat mild to moderate inflammation in ulcerative colitis. By controlling inflammation, these drugs are generally effective at inducing and maintaining remission of disease. They include sulphasalazine, mesalazine, olsalazine and balsalazide (a pro drug). Possible side effects of 5-ASA preparations include nausea, vomiting, heartburn, diarrhoea and headaches.
Corticosteroids
People with severe disease and those who do not respond to 5-ASA preparations may be treated with added corticosteroids. Prednisone, budesonide and hydrocortisone are corticosteroids used to reduce inflammation. They can be given orally, intravenously, through an enema, or in a suppository, depending on the location of the inflammation. Corticosteroids can cause side effects such as weight gain, acne, facial hair, hypertension, diabetes, mood swings and an increased risk of infection, so doctors carefully monitor patients taking these medications.
Immunosuppressants
Immunosuppressants such as azathioprine 6-MP and methotrexate are often used and can make a marked improvement at low doses with few side effects. Other drugs may be given to relax the patient or to relieve pain, diarrhoea, or infection. Occasionally, a person may have severe bleeding or severe diarrhoea that causes dehydration. In such cases they may need hospitalisation, and may need a special diet, parenteral nutrition, medications and sometimes surgery.
Biologic Agents
Biologic Agents are medications that they be prescribed to treat moderate to severe disease that is non-responsive to other forms of treatment.
Surgery
In severe cases a patient may need surgery to remove the diseased colon if medical treatment fails, or if the side effects of corticosteroids or other drugs threaten the patient’s health. Most people with ulcerative colitis will never need to have surgery. If surgery ever does become necessary, some people find comfort in knowing that after surgery, the colitis segment is removed and they can return to living a normal, active life.
