What Is Ulcerative Colitis

Ulcerative colitis is an inflammatory bowel syndrome affecting the large intestine, characterized by ulcers or sores which develop on the wall of the large bowel, resulting in recurrent bloody diarrhea accompanied by fever, and abdominal pain and cramping.

  • Intermittent bouts of diarrhea, with stools mixed with blood, abdominal pain and cramps, and fever, are the usual symptoms
  • The reason for the development of ulcerative colitis is unknown.
  • Colonoscopy to examine the interiors of the colon, and sigmoidoscopy to detect abnormalities in the sigmoid colon, which is the last part of the large intestine, are the usual tests for diagnosing this condition.
  • Ulcerative colitis for prolonged periods may lead to the development of colon cancer.
  • The treatment focuses on reducing the inflammation and alleviating the symptoms.

Ulcerative colitis usually start developing in people in the age group 15-30 years, but sometimes it appears as late as when a person is over 50 years also.

Ulcerative colitis is often restricted to the large intestine; the inflammation usually starting in the rectum and then spreading upward into the sigmoid colon, which is the last portion of the large intestine. The disease may gradually spread further, to cover the whole length of the large intestine. However, it rarely affects the small intestine. Ulcerative colitis is limited to the inner wall of the bowel too, usually not affecting the entire thickness.

When the inflammation is restricted to the rectum, it is termed as ulcerative proctitis, which is the more common and less troublesome form of ulcerative colitis. But in several cases, within a short period, the inflammation affects the colon too.

The exact reason for the development of ulcerative colitis is still unknown but is thought to be resulting from the over reaction of the immune system. Hereditary factor also is suspected, as most people suffering from this condition usually have a close relative with the same disease. Smoking is found to trigger flare ups of Crohn’s disease but contrary to expectation, it is found to reduce the risk of developing colitis. However, smoking, as a way to prevent ulcerative colitis, is not recommended at all, as the ill effects of smoking far outweighs the benefits.

Symptoms

Ulcerative colitis has active and passive phases which occur intermittently. The typical symptoms appear during the flare ups. During a severe flare up which may occur suddenly, it causes severe bloody diarrhea accompanied by pain in the abdomen and high fever. The peritoneal lining of the abdomen also may become inflamed leading to a condition called peritonitis. Flare ups may start any time, and each episode may last from several days to many weeks. People become severely ill during this time. Usually, the flare ups may be milder, and develop gradually, beginning with an urgency to defecate. It may be accompanied by milder abdominal cramps and blood stained stools.

When ulcerative colitis is restricted to the last portion of the colon and the rectum only, diarrhea may not be present. The stool may be well-formed and dry, but it may contain large amounts of blood stained mucus produced by the rectum. Other symptoms such as fever may be completely absent or may be present in a milder form.

When ulcerative colitis has spread to most parts of the large bowel, it results in frequent bowel movements, sometimes as frequent as ten to twenty times a day. The watery stools usually contain blood, mucus and pus. Often, the stool may be just pus and blood. The frequent urge to have a bowel movement is usually accompanied by painful abdominal spasms and cramping, even during the night. Fever may be present and loss of appetite may lead to weight loss.

Complications: Bleeding from the rectum is one of the complications which results in anemia. In one tenth of people with this condition, the initial attack is extremely severe, accompanied by fever as well as bleeding, and may result in spread of infections and perforations of the intestine.

Another complication of ulcerative colitis is the development of toxic colitis, a condition in which the disease damages the whole thickness of bowel wall. It may lead to ileus or the temporary halting of the normal peristaltic movements of the intestine. This causes the contents of the bowel to stagnate, resulting in the distention of the abdomen. Eventually, the muscle tone of the large intestine is lost, and the paralyzed parts start to enlarge, filling up with gas.

Toxic megacolon is a dangerous complication which develops when the large bowel becomes greatly distended. Abdominal pain and high fever are usually present, and the WBC count is elevated. There is a high risk of the intestine rupturing and leading to a potentially fatal situation. Toxic megacolon is a medical emergency, and with immediate treatment, the rupture of the intestine and the fatal outcome may be prevented.

Colon cancer is another potentially fatal complication developing in about 1% of those who have long-standing ulcerative colitis. The risk of developing colon cancer depends on the duration and extent of the disease; the risk being highest when the whole of the large intestine is involved, and the when the disease has been present for more than eight years. That is the reason why people suffering from ulcerative colitis should undergo a viewing test called colonoscopy every year or at least once in two years, especially after about eight years from the onset of the disease. In addition to viewing the interiors of the colon and the rectum for abnormalities, a tissue sample for biopsy is also collected using the colonoscope. The biopsy can detect precancerous conditions like dysplasia. Appropriate treatment initiated on the detection of dysplasia, or even in the initial stages of cancer, can be lifesaving. Surgical removal of colon effectively cures the cancer at this stage.

Several other complications of ulcerative colitis include inflammatory conditions in other parts of the body which develop during the flare-ups. Episcleritis, which is the inflammation of the sclera or the white part of the eye ball, arthritis characterized by painful inflammation and stiffness of the joints, or inflamed nodules developing on the hands and legs called erythema nodosum, and pyoderma gangrenosum, in which pus-filled, blue-red sores break out on the skin, are some of the complications.

In people with ulcerative colitis, even during the remission period, inflammatory conditions such as pyoderma gangrenosum, uveitis or eye inflammation, sacroiliitis or inflammation in the pelvic joint and ankylosing spondylitis or the inflammation occurring in the spine, are usually found. Blood clot formation in the veins is a rare but dangerous complication which may occur in people with ulcerative colitis.

Liver dysfunction is common in those who have ulcerative colitis, but it is usually a minor dysfunction. However, up to three cases out of every hundred may develop mild or severe forms of liver disease. When the liver disease is severe, wide ranging inflammations may occur, such as active hepatitis caused by liver inflammation and primary sclerosing cholangitis, which is bile duct inflammation. Chronic inflammation of the liver may cause the normal liver tissue to be replaced by scar tissue, resulting in cirrhosis. Inflamed bile ducts may become narrowed and get completely closed. Inflamed bile ducts have a higher risk of developing into cholangiocarcinoma or bile duct cancer. The risk of developing colon cancer is usually found to have a direct link to the incidence of cholangiocarcinoma.

Diagnosis

The typical symptoms of the ulcerative colitis, and a stool test, help the doctor to diagnose this disease. There are no specific blood tests to detect this condition. Low hemoglobin count, higher than normal WBC count, high ESR rate, and low blood levels of albumin, may be indicative of anemia and inflammation. When the sigmoid part of the colon is examined with a viewing tube called sigmoidoscope, the abnormalities and signs of inflammation observed, help confirm the disease. A biopsy is also done, and the detailed examination of the tissue sample may reveal inflammation, which is taken as a conclusive evidence of the disease.

An x-ray can show the location and spread of the inflammation, but barium enema x-ray is not done when the disease is in the active phase. Colonoscopy is also avoided during this time, but it is conducted later to examine the whole of the large intestine and determine the severity and spread of ulcerative colitis.

Prognosis and Treatment

This chronic inflammatory bowel syndrome is characterized by active and passive phases, which appear intermittently throughout a person’s life. The initial attack of ulcerative colitis, which is usually severe, results in the quick spread of the inflammation and the development of complications associated with it. In around ten cases out of a hundred, people recover completely after the first attack. However, there is a possibility that the typical symptoms of ulcerative colitis displayed during the attack may have been the result of some other severe infection. A biopsy of a tissue sample from the colon may help in proper diagnosis.

The prognosis of people with ulcerative proctitis is very good as they usually have no major complications. But in 10% to 30% of cases, the inflammation may progress into ulcerative colitis affecting the large bowel.

The treatment of ulcerative colitis is focused on bringing the inflammation under control and alleviating symptoms and ensuring quality of life. There is no permanent cure for this disease except the complete removal of the rectum as well as the large intestine.

Dietary Restrictions: People with ulcerative colitis are usually advised to avoid raw vegetables and fresh fruits, as they may worsen the inflammation of the intestinal lining. A dairy-free diet is found to be effective in reducing symptoms in some people. It can be tried, and if found to be beneficial, can be continued for better management of the disease. Supplemental iron should be taken to prevent anemia due to frequent bleeding from the rectum.

Antidiarrheal Drugs: Anticholinergic drugs, including antihistamines and certain antidepressants, are effective in controlling diarrhea. Depending on the severity of the diarrhea, the drug loperamide or another drug diphenoxylate may be taken in small or high doses. Codeine and deodorized tincture of opium are also used to control severe diarrhea. Antidiarrheal medication in high doses should be used under medical supervision to prevent the potentially fatal condition called toxic megacolon from developing.

Anti-Inflammatory Drugs:  Sulfasalazine, and related drugs mesalamine, olsalazine as well as balsalazide may help in treating ulcerative colitis, as they can bring down inflammation and the severity of symptoms. They are most effective in treating mild to moderate forms of the disease; and they help prevent frequent flare ups and maintain remission for longer periods. The risk of developing cancers of the colon or the rectum may be decreased by the use of these drugs.

The use of corticosteroids like prednisone has an immediate beneficial effect on patients with severe or moderately severe form of ulcerative colitis. Prednisone can be taken orally, but high doses may be needed initially, to bring the disease under control. After some amount of control is achieved, the drug sulfasalazine or other related drugs such as mesalamine or olsalazine are used for the maintenance of the remission. To reduce the side effects of long-term corticosteroid usage, predinisone is gradually weaned off. When the disease is mild and is restricted to the rectum and to the descending colon on the left side of the body, corticosteroids as well as mesalamine may be administered as suppositories or enemas.

Hospitalization of the patient may be necessary in severe cases of ulcerative colitis. All medications, nutritional support and rehydration therapy are administered intravenously till the condition improves. If blood loss has been heavy, blood transfusion may be given.

Immunomodulating Drugs: Mercaptopurine and  azathioprine  are immunomodulators used to treat ulcerative colitis. They reduce the immune response of the body by inhibiting the normal actions of T cells, and help avoid the log-term use of corticosteroids. The drawback is that their action is slow and it may take one to four months before any tangible benefits are felt. Their potential side effects are also a cause of concern, and the patients taking these medications have to be closely monitored during the therapy for adverse reactions.

The drug cyclosporine is found to be effective in some cases which show poor response to corticosteroids. But the beneficial effect is often temporary, and in some cases, surgery may have to be done eventually.

The comparatively new drug Infliximab, synthesized from monoclonal antibodies, is found to be effective in the treatment of ulcerative colitis in some people, whose response to immunomodulating drugs as well as corticosteroid therapy is not adequate.

Surgery: Around 30% of the ulcerative colitis cases may require surgical intervention at some time or the other. The surgery can be an emergency procedure or a pre-planned event. Perforations of the intestine, heavy bleeding, formation of blood clots, and toxic megacolon, are some of the potentially dangerous situations which necessitate emergency surgical intervention. Biopsy showing dysplasia, and colon cancer detected in the early stages, and narrowing of the large bowel, are the usual reasons for planned surgeries. When the symptoms of ulcerative colitis remain severe despite possible drug therapies, surgery is an option. Sometimes surgery is performed to avoid constant heavy use of corticosteroids, and to prevent growth retardation due to frequent flare ups, and malabsorption, in children.

Since ulcerative colitis is normally restricted to the large bowel and the rectum, surgical removal of these parts of the digestive tract effectively cures the disease. Earlier, this surgery used to be followed by an ileostomy, by which an outlet for excretion is created in the abdominal wall, to which the ileum or the last portion of the small intestine is attached. Patients had to carry a removable plastic bag to collect stool which is attached to the opening by a plastic tube. Now there are better options available, such as ileo-anal anastomosis in which normal defecation is made possible. After the removal of the large bowel and the major portion of the rectum, the cut end of small intestine is enlarged to form a reservoir for stool, which is then attached to the remaining portion of the rectum. Since the anal sphincter is left intact, it ensures fecal continence and the patient is able to lead a normal life. However, the reservoir may get inflamed, resulting in a condition called pouchitis.

Surgery is not necessary to treat ulcerative proctitis. But some cases may not be responsive to treatment and the symptoms may not subside easily. But it does not in any way affect the life span of a person.

When a potentially fatal complication called toxic megacolon is detected, it is treated as a medical emergency. The patient is put on fast and antidiarrheal medications are stopped. A suction tube is inserted into the small intestine via the nose, to remove the contents and secretions of the stomach and the intestine from time to time. All the necessary drugs and nutritional feeding are administered intravenously. The patient is kept under observation to detect perforation of the intestine and the development of peritonitis. Infliximab or cyclosporine may be given, depending on the patient’s condition. The large intestine is either partially, or totally, removed in an emergency operation, if the other measures do not improve the condition.

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Yasser Elnahas

MD, PHD, Professor Of CardioVascular Surgery
Dr. Yasser Elnahas, Is an associate Professor of Cardiovascular Surgery. Dr. Elnahas was trained as a fellow At Texas Heart Institute And Mayo Clinic Foundation.Dr. Elnahas is dedicated to educating the general public about different disease conditions and simplifying the medical knowledge in an easy to understand terminology.

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