What is Ulcerative colitis?

Ulcerative colitis is a complex intestinal disorder  characterised by chronic inflammation of the large intestine (colon). Unlike Crohn’s disease, the inflammation is restricted to the colon. This inflammation invariably results in bloody diarrhea. The inflammation tends to be confluent often starting in the rectum. However, varying amounts of the colon can be involved. When the inflammation is restricted to the rectum it is called ulcerative proctitis. If the entire colon is affected it is called pancolitis. If only the left side of the colon is affected it is called limited or distal colitis. Ulcerative colitis is a chronic inflammatory bowel disease (IBD). It can be difficult to diagnose because its symptoms are similar to other intestinal disorders and to another type of IBD called Crohn’s disease. However, Crohn’s disease differs because it causes inflammation deeper within the intestinal wall and can occur in other parts of the digestive system including the small intestine, mouth, esophagus, and stomach.

Ulcerative colitis can occur in people of any age, but it usually develops between the ages of 15 and 30, and less frequently between 50 and 70 years of age. It affects men and women equally and appears to run in families, with reports of up to 20 percent of people with ulcerative colitis having a family member or relative with ulcerative colitis or Crohn’s disease.

What are the symptoms of ulcerative colitis?

The most common symptoms of ulcerative colitis are abdominal pain and bloody diarrhea. Patients also may experience;

Anaemia

Tiredness

Weight loss

Loss of appetite

Rectal bleeding

Rashes

Joint pain

Growth failure (specifically in children).

About half of the people diagnosed with ulcerative colitis have mild symptoms. Others suffer frequent fevers, bloody diarrhea, nausea, and severe abdominal cramps and may require to be admitted to hospital for emergency treatment. Ulcerative colitis may also cause problems such as arthritis, inflammation of the eye, liver disease, and osteoporosis. It is not known why these problems occur outside the colon. Scientists think these complications may be the result of inflammation triggered by the immune system. Some of these problems go away when the colitis is treated.

What causes Ulcerative colitis?

The cause of  Ulcerative colitis is not clear. The development of disease in any one individual is the result of an interaction between a genetic susceptibility and environmental factors. The spectrum of disease severity from mild to severe reflects this complex interplay between different factors.

How is Ulcerative colitis diagnosed?

A physical exam and medical history are usually the first step.

Blood tests will be performed to check for anaemia, which could indicate bleeding in the colon and to look for signs of inflammation somewhere in the body.

A stool sample for culture is very important to exclude infection.

A colonoscopy is the most sensitive investigation for making a diagnosis of ulcerative colitis and ruling-out other possible conditions, such as Crohn’s disease, diverticular disease, or cancer. The endoscopist will be able to see any inflammation, bleeding, or ulcers on the colon wall. During the exam, the doctor may do a biopsy, which involves taking a sample of tissue from the lining of the colon to view with a microscope.

What is the treatment for ulcerative colitis?

Treatment for ulcerative colitis will depend on the severity of the disease. However medical therapy is always the first line of treatment.

Drug Therapy

The goal of drug therapy is to induce and maintain remission, and to improve the quality of life for people with ulcerative colitis. Several types of drugs are available.

Aminosalicylates, drugs that contain 5-aminosalicyclic acid (5-ASA), help control inflammation. 5-ASA agents, such as olsalazine, mesalamine, and balsalazide, are usually very well tolerated with few side effects when compared to older preparations. 5-ASAs are given orally, through an enema, or in a suppository, depending on the location of the inflammation in the colon. Most people with mild or moderate ulcerative colitis are treated with this group of drugs first. This class of drugs is also used in cases of relapse.

Corticosteroids such as prednisone, methylprednisone, and hydrocortisone also reduce inflammation. They may be used by people who have moderate to severe ulcerative colitis or who do not respond to 5-ASA drugs. Corticosteroids, also known as steroids, can be given orally, intravenously, an enema, or in a suppository, depending on the location of the inflammation. These drugs can cause side effects such as weight gain, acne, facial hair, hypertension, diabetes, mood swings, bone mass loss, and an increased risk of infection. For this reason, they are not recommended for long-term use, although they are considered very effective when prescribed for short-term use.

Immunomodulators such as azathioprine and 6-mercapto-purine (6-MP) reduce inflammation by affecting the immune system. These drugs are used for patients who have not responded to 5-ASAs or corticosteroids or who are dependent on corticosteroids. Immunomodulators are administered orally, however, they are slow acting and it may take up to 3 months before the full benefit. Patients taking these drugs are monitored for possible side effects that include pancreatitis, hepatitis, a reduced white blood cell count, and an increased risk of infection. Ciclosporine A may be used with 6-MP or azathioprine to treat active, severe ulcerative colitis in people who do not respond to intravenous corticosteroids.

Some people have remissions—periods when the symptoms go away—that last for months or even years. However, most patients’ symptoms eventually return.

Hospitalization

Occasionally, symptoms are severe enough that a person must be hospitalized. For example, a person may have severe bleeding or severe diarrhea that causes dehydration. In such cases the doctor will try to stop diarrhea and loss of blood, fluids, and mineral salts. The patient may need a special diet, feeding through a vein, medications, or sometimes surgery.

Surgery

About 25 to 30 percent of ulcerative colitis patients must eventually require surgery because of severe acute or chronic refractory disease.  Surgery to remove the colon and rectum, known as proctocolectomy, is followed by one of the following:

Ileostomy, in which the surgeon creates a small opening in the abdomen, called a stoma, and attaches the end of the small intestine, called the ileum, to it. Waste will travel through the small intestine and exit the body through the stoma. The stoma is about the size of a quarter and is usually located in the lower right part of the abdomen near the beltline. A stoma bag is worn over the opening to collect waste, and the patient empties the stoma as needed.

Ileoanal anastamosis (IPAA, or pull-through operation, which allows the patient to have normal bowel movements because it preserves part of the anus. In this operation, the surgeon removes the colon and the inside of the rectum, leaving the outer muscles of the rectum. The surgeon then attaches the ileum to the inside of the rectum and the anus, creating a pouch. Waste is stored in the pouch and passes through the anus in the usual manner. Bowel movements may be more frequent and watery than before the procedure. Inflammation of the pouch (pouchitis) is a possible complication.

Not every operation is appropriate for every person. Which surgery to have depends on the severity of the disease and the patient’s needs, expectations, and lifestyle. People faced with this decision should get as much information as possible by talking to their doctors, IBD nurse specialists and other patients have had surgery. NACC provide good advice and support.