Ulcerative colitis

Definition

Ulcerative colitis is a type of inflammatory bowel disease (IBD) that affects the lining of the large intestine (colon) and rectum.

See also: Crohn's disease

Alternative Names

Inflammatory bowel disease - ulcerative colitis; IBD - ulcerative colitis

Causes, incidence, and risk factors

The cause of ulcerative colitis is unknown. People with this condition have problems with the immune system, but it is not clear whether immune problems cause this illness. Although stress and certain foods can trigger symptoms, they do not cause ulcerative colitis.

Ulcerative colitis may affect any age group, although there are peaks at ages 15 - 30 and then again at ages 50 - 70.

The disease usually begins in the rectal area, and may involve the entire large intestine over time.

Risk factors include a family history of ulcerative colitis, or Jewish ancestry.

Symptoms

The symptoms vary in severity and may start slowly or suddenly. About half of people only have mild symptoms. Others have more severe attacks that occur more often. Many factors can lead to attacks, including respiratory infections or physical stress.

Symptoms include:

• Abdominal pain and cramping that usually disappears after a bowel movement
• Abdominal sounds (a gurgling or splashing sound heard over the intestine)
• Blood and pus in the stools
• Diarrhea, from only a few episodes to very often throughout the day
• Fever
• Tenesmus (rectal pain)
• Weight loss

Children's growth may slow.

Other symptoms that may occur with ulcerative colitis include the following:

• Gastrointestinal bleeding
• Joint pain
• Mouth sores (ulcers)
• Nausea and vomiting
• Skin lumps or ulcers

Signs and tests

Colonoscopy with biopsy is generally used to diagnose ulcerative colitis.

Colonoscopy is also used to screen people with ulcerative colitis for colon cancer. Ulcerative colitis increases the risk of colon cancer. If you have this condition, you should be screened with colonoscopy about 8 - 12 years after being diagnosed. You should have a follow-up colonoscopy every 1 - 2 years.

Other tests that may be done to help diagnose this condition include:

• Barium enema
• Complete blood count (CBC)
• C-reactive protein (CRP)
• Sedimentation rate (ESR)

Treatment

The goals of treatment are to:

• Control the acute attacks
• Prevent repeated attacks
• Help the colon heal

Hospitalization is often needed for severe attacks. Your doctor may prescribe corticosteroids to reduce inflammation. You may be given nutrients through a vein (intravenous line).

DIET AND NUTRITION

Certain types of foods may worsen diarrhea and gas symptoms, especially during times of active disease. Diet suggestions include:

• Eat small amounts of food throughout the day.
• Drink plenty of water (drink small amounts throughout the day).
• Avoid high-fiber foods (bran, beans, nuts, seeds, and popcorn).
• Avoid fatty, greasy or fried foods and sauces (butter, margarine, and heavy cream).
• Limit milk products if you are lactose intolerant. Dairy products are a good source of protein and calcium.

STRESS

You may feel worried, embarrassed, or even sad or depresed about having a bowel accident. Other stressful events in your life, such as moving, or losing a job or a loved one can cause digestive problems.

Ask your doctor or nurse for tips on your to manage your stress.

MEDICATIONS

Medications that may be used to decrease the number of attacks include:

• 5-aminosalicylates such as mesalamine or sulfazine, which can help control moderate symptoms
• Immunomodulators such as azathioprine and 6-mercaptopurine
• Corticosteroids (prednisone and methylprednisolone) taken by mouth during a flare-up or as a rectal suppository, foam, or enema
• Infliximab (Remicade) or other biological treatments, if you do not respond to other medications

SURGERY

Surgery to remove the colon will cure ulcerative colitis and removes the threat of colon cancer. Surgery is usually recommended for patients who have:

• Colitis that does not respond to complete medical therapy
• Changes in the lining of the colon that are thought to be precancerous
• Serious complications such as rupture (perforation) of the colon, severe bleeding (hemorrhage), or toxic megacolon

Most of the time, the entire colon, including the rectum, is removed. Afterwards, patients may need a surgical opening in the abdominal wall (ileostomy), or a procedure that connects the small intestine to the anus to help the patient gain more normal bowel function.

See also:

• Total proctocolectomy with ileostomy
• Total proctocolectomy and ileal - anal pouch

Support Groups

Social support can often help with the stress of dealing with illness, and support group members may also have useful tips for finding the best treatment and coping with the condition.

For more information, visit the Crohn's and Colitis Foundation of America (CCFA) web site at www.ccfa.org.

Expectations (prognosis)

About half of patients with ulcerative colitis have mild symptoms. Patients with more severe ulcerative colitis tend to respond less well to medications.

Permanent and complete control of symptoms with medications is unusual. Cure is only possible through complete removal of the large intestine.

The risk of colon cancer increases in each decade after ulcerative colitis is diagnosed.

Complications

Repeated swelling (inflammation) leads to thickening of the intestinal wall and rectum with scar tissue. Death of colon tissue or severe infection (sepsis) may occur with severe disease.

• Ankylosing spondylitis
• Blood clots
• Colorectal cancer
• Colon narrowing
• Complications of corticosteroid therapy
• Impaired growth and sexual development in children
• Inflammation of the joints (arthritis)
• Liver disease
• Massive bleeding in the colon
• Mouth ulcers
• Pyoderma gangrenosum (skin ulcer)
• Sores (lesions) in the eye
• Tears or holes (perforation) in the colon

Calling your health care provider

Call your health care provider if:

• You develop persistent abdominal pain, new or increased bleeding, persistent fever, or other symptoms of ulcerative colitis
• You have ulcerative colitis and your symptoms worsen or do not improve with treatment, or new symptoms develop

Prevention

Because the cause is unknown, prevention is also unknown.

Nonsteroidal anti-inflammatory drugs (NSAIDs) may make symptoms worse.

Due to the risk of colon cancer associated with ulcerative colitis, screening with colonoscopy is recommended.

The American Cancer Society recommends having your first screening:

• 8 years after you are diagnosed with severe disease, or when most of, or the entire, large intestine is involved
• 12 - 15 years after diagnosis when only the left side of the large intestine is involved

Have follow-up examinations every 1 - 2 years.

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References

Sands BE, Siegel CA. Crohn's disease. In: Feldman M, Friedman LS, Brandt, LJ, eds. Sleisenger & Fordtran's Gastrointestinal and Liver Disease. 9th ed. Philadelphia, Pa: Saunders Elsevier;2010:chap 111.

Moyer MS. Chronic ulcerative colitis in childhood. J Pediatr. 2006;148:325.

Fry RD, Mahmoud N, Maron DJ, Ross HM, Rombeau J. Colon and rectum. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 50.

Rutgeerts P, Vermeire S, Van Assche G. Biological therapies for inflammatory bowel diseases. Gastroenterology. 2009;136(4):1182-1197.