Ulcerative colitis

Synonyms

1

Overview

Ulcerative colitis (UC) is a form of inflammatory bowel disease (IBD) that causes inflammation and ulcers in the colon. The disease is a type of colitis, which is a group of diseases that cause inflammation of the colon, the largest section of the large intestine, either in segments or completely. The main symptom of active disease is diarrhea mixed with blood.

Ulcerative colitis newly occurs in 1 to 20 people per 100,000 per year, and about 8 to 246 per 100,000 individuals are affected. The disease is more common in northern regions of the world. Rates tend to be higher in wealthier countries, which may indicate the increased rate is due to better diagnosis. It may also indicate that an industrial or Western diet and lifestyle increases the rate of disease, including symptoms which may or may not be related to ulcerative colitere is a presumed genetic risk. The disease may be triggered in a susceptible person by environmental factors. Dietary modification may reduce the discomfort of a person with the disease. is. Ulcerative colitis can be debilitating and sometimes can lead to life-threatening complications. While it has no known cure, treatment can greatly reduce signs and symptoms of the disease and even bring about long-term remission.

Symptoms

Ulcerative colitis symptoms can vary, depending on the severity of inflammation and where it occurs. Therefore, doctors often classify ulcerative colitis according to its location.

The following signs and symptoms may appear, depending on which part of the colon is inflamed:

  • Diarrhea, often with blood or pus 
  • Abdominal pain and cramping 
  • Rectal pain 
  • Rectal bleeding — passing small amount of blood with stool 
  • Urgency to defecate 
  • Inability to defecate despite urgency 
  • Weight loss 
  • Fatigue 
  • Fever 
  • In children, failure to grow 

Most people with ulcerative colitis have mild to moderate symptoms. The course of ulcerative colitis may vary, with some people having long periods of remission.

Causes

The exact cause of ulcerative colitis remains unknown. Previously, diet and stress were suspected, but now doctors know that these factors may aggravate but don't cause ulcerative colitis.

One possible cause is an immune system malfunction. When your immune system tries to fight off an invading virus or bacterium, an abnormal immune response causes the immune system to attack the cells in the digestive tract, too.

Heredity also seems to play a role in that ulcerative colitis is more common in people who have family members with the disease. However, most people with ulcerative colitis don't have this family history.

Ulcerative colitis affects about the same number of women and men. Risk factors may include:

  • Age. Ulcerative colitis usually begins before the age of 30. But, it can occur at any age, and some people may not develop the disease until after age 60.
  • Race or ethnicity. Although whites have the highest risk of the disease, it can occur in any race. If you're of Ashkenazi Jewish descent, your risk is even higher.
  • Family history. You're at higher risk if you have a close relative, such as a parent, sibling or child, with the disease.
  • Isotretinoin use. Isotretinoin (Amnesteem, Claravis, Sotret; formerly Accutane) is a medication sometimes used to treat scarring cystic acne or acne. Some studies suggest it is a risk factor for IBD, but a clear association between ulcerative colitis and isotretinoin has not been established.

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.

Diagnosis

The initial diagnostic workup for ulcerative colitis includes the following:

  • A complete blood count is done to check for anemia; thrombocytosis, a high platelet count, is occasionally seen
  • Electrolyte studies and renal function tests are done, as chronic diarrhea may be associated with hypokalemia, hypomagnesemia and pre-renal failure.
  • Liver function tests are performed to screen for bile duct involvement: primary sclerosing cholangitis.
  • X-ray
  • Urinalysis
  • Stool culture, to rule out parasites and infectious causes.
  • Erythrocyte sedimentation rate can be measured, with an elevated sedimentation rate indicating that an inflammatory process is present.
  • C-reactive protein can be measured, with an elevated level being another indication of inflammation.
  • sigmoidoscopy a type of endoscopy can detect presence of ulcers in the large intestine after a trial of enema.

Although ulcerative colitis is a disease of unknown causation, inquiry should be made as to unusual factors believed to trigger the disease. Factors may include: recent cessation of tobacco smoking; recent administration of large doses of iron or vitamin B6; hydrogen peroxide in enemas or other procedures.

Endoscopic

The best test for diagnosis of ulcerative colitis remains endoscopy. Full colonoscopy to the cecum and entry into the terminal ileum is attempted only if diagnosis of UC is unclear. Otherwise, a flexible sigmoidoscopy is sufficient to support the diagnosis. The physician may elect to limit the extent of the exam if severe colitis is encountered to minimize the risk of perforation of the colon. Endoscopic findings in ulcerative colitis include the following:

  • Loss of the vascular appearance of the colon
  • Erythema (or redness of the mucosa) and friability of the mucosa
  • Superficial ulceration, which may be confluent, and
  • Pseudopolyps.

Ulcerative colitis is usually continuous from the rectum, with the rectum almost universally being involved. There is rarely perianal disease, but cases have been reported. The degree of involvement endoscopically ranges from proctitis or inflammation of the rectum, to left sided colitis, to pancolitis, which is inflammation involving the ascending colon.

Histologic

Biopsies of the mucosa are taken to definitively diagnose UC and differentiate it from Crohn's disease, which is managed differently clinically. Microbiological samples are typically taken at the time of endoscopy. The pathology in ulcerative colitis typically involves distortion of crypt architecture, inflammation of crypts (cryptitis), frank crypt abscesses, and hemorrhage or inflammatory cells in the lamina propria. In cases where the clinical picture is unclear, the histomorphologic analysis often plays a pivotal role in determining the diagnosis and thus the management. By contrast, a biopsy analysis may be indeterminate, and thus the clinical progression of the disease must inform its treatment.

Prognosis

Progresion or remision

Patients with ulcerative colitis usually have an intermittent course, with periods of disease inactivity alternating with "flares" of disease. Patients with proctitis or left-sided colitis usually have a more benign course: only 15% progress proximally with their disease, and up to 20% can have sustained remission in the absence of any therapy. Patients with more extensive disease are less likely to sustain remission, but the rate of remission is independent of the severity of disease.

Ulcerative colitis and colorectal cancer

There is a significantly increased risk of colorectal cancer in patients with ulcerative colitis after ten years if involvement is beyond the splenic flexure. Those with only proctitis or rectosigmoiditis usually have no increased risk. It is recommended that patients have screening colonoscopies with random biopsies to look for dysplasia after eight years of disease activity, at one to two year intervals.

Primary sclerosing cholangitis

Ulcerative colitis has a significant association with primary sclerosing cholangitis (PSC), a progressive inflammatory disorder of small and large bile ducts. As many as 5% of patients with ulcerative colitis may progress to develop primary sclerosing cholangitis.

Mortality

Research has not revealed any difference in overall risk of dying in patients with Ulcerative colitis from that of the background population. The cause-of-death distribution may be different from that of the background population. It is thought that the disease primarily affects quality of life, and not lifespan.

Other long-term features

Changes that can be seen in chronic ulcerative colitis include granularity, loss of the vascular pattern of the mucosa, loss of haustra, effacement of the ileocecal valve, mucosal bridging, strictures and pseudopolyps.

Treatment

Ulcerative colitis treatment usually involves either drug therapy or surgery. Several categories of drugs may be effective in treating ulcerative colitis. The type you take will depend on the severity of your condition. The drugs that work well for some people may not work for others, so it may take time to find a medication that helps you. In addition, because some drugs have serious side effects, you'll need to weigh the benefits and risks of any treatment.

Anti-inflammatories:

Anti-inflammatory drugs are often the first step in the treatment of inflammatory bowel disease. They include:

  • Aminosalicylates. Sulfasalazine (Azulfidine) can be effective in reducing symptoms of ulcerative colitis, but it has a number of side effects, including digestive distress and headache. Certain 5-aminosalicylates, including mesalamine (Asacol, Lialda, Rowasa, Canasa, others), balsalazide (Colazal) and olsalazine (Dipentum) are available in both oral and enema or suppository forms. Which form you take depends on the area of your colon that's affected. Rarely, these medications have been associated with kidney and pancreas problems.
  • Corticosteroids. These drugs, which include prednisone and hydrocortisone, are generally reserved for moderate to severe ulcerative colitis that doesn't respond to other treatments. They are given orally, intravenously, or by enema or suppository, depending on the location affected.

Corticosteroids have numerous side effects, including a puffy face, excessive facial hair, night sweats, insomnia and hyperactivity. More-serious side effects include high blood pressure, diabetes, osteoporosis, bone fractures, cataracts, glaucoma and increased chance of infection. They are not usually given long term.

Immunosupressants:

These drugs also reduce inflammation, but they do so by suppressing the immune system response that starts the process of inflammation. For some people, a combination of these drugs works better than one drug alone. 

Immunosuppressant drugs include:

  • Azathioprine (Azasan, Imuran) and mercaptopurine (Purinethol, Purixam). These are the most widely used immunosuppressants for treatment of inflammatory bowel disease. Taking them requires that you follow up closely with your doctor and have your blood checked regularly to look for side effects, including effects on the liver and pancreas. Additional side effects include lowered resistance to infection and a small chance of developing cancers such as lymphoma and skin cancers.
  • Cyclosporine (Gengraf, Neoral, Sandimmune). This drug is normally reserved for people who haven't responded well to other medications. Cyclosporine has the potential for serious side effects, such as kidney and liver damage, seizures, and fatal infections, and is not for long-term use. There's also a small risk of cancer, so let your doctor know if you've previously had cancer.
  • Infliximab (Remicade), adalimumab (Humira) and golimumab (Simponi). These drugs, called tumor necrosis factor (TNF)-alpha inhibitors, or "biologics," work by neutralizing a protein produced by your immune system. They are for people with moderate to severe ulcerative colitis who don't respond to or can't tolerate other treatments. People with certain conditions can't take TNF-alpha inhibitors. Tuberculosis and other serious infections have been associated with the use of immunosuppressant drugs. These drugs also are associated with a small risk of developing certain cancers such as lymphoma and skin cancers.
  • Vedolizumab (Entyvio). This medication was recently approved for treatment of ulcerative colitis for people who don't respond to or can't tolerate biologics and other treatments. It works by blocking inflammatory cells from getting to the site of infection. It is also associated with a small risk of infection and cancer.

Other medications:

You may need additional medications to manage specific symptoms of ulcerative colitis. Always talk with your doctor before using over-the-counter medications. He or she may recommend one or more of the following.

  • Antibiotics. People with ulcerative colitis who run fevers will likely take antibiotics to help prevent or control infection.
  • Anti-diarrheal medications. For severe diarrhea, loperamide (Imodium) may be effective. Use anti-diarrheal medications with great caution, however, because they may increase the risk of toxic megacolon.
  • Pain relievers. For mild pain, your doctor may recommend acetaminophen (Tylenol, others) — but not ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve, Anaprox), and diclofenac sodium (Voltaren, Solaraze), which can worsen symptoms and increase the severity of disease.
  • Iron supplements. If you have chronic intestinal bleeding, you may develop iron deficiency anemia and be given iron supplements.

Surgery:
Surgery can often eliminate ulcerative colitis. But that usually means removing your entire colon and rectum (proctocolectomy). In most cases, this involves a procedure called ileoanal anastomosis that eliminates the need to wear a bag to collect stool. Your surgeon constructs a pouch from the end of your small intestine. The pouch is then attached directly to your anus, allowing you to expel waste relatively normally.