What is Ulcerative Colitis?
Ulcerative colitis is one of the main subtypes of inflammatory bowel disease (IBD). Inflammatory bowel disease causes chronic inflammation in the intestinal tract, which leads to a variety of symptoms and can lead to involvement of other organ systems. IBD is a lifelong disease with periods of active disease alternating with periods of disease control (remission). IBD is sometimes confused with but is different than irritable bowel syndrome (IBS).
In ulcerative colitis, inflammation occurs only in the large intestine (colon) and is limited to the inner lining of the intestinal wall. The inflammation nearly always starts in the lowest part of the colon (the rectum) and extends upwards in continuous pattern. The length of colon that is involved varies between patients. In some patients, the inflammation is confined to the rectum only, in others it extends part of the way up the colon, and in others it involves the entire colon. Because the inflammation is confined to the colon, ulcerative colitis is curable by surgical removal of the colon.
There are more than 1 million people with IBD in the United States with new cases diagnosed at a rate of 10 cases per 100,000 people. These diseases account for 700,000 physician visits per year and 100,000 hospitalizations per year in the United States. Ulcerative colitis can be cured with surgery but Crohn’s disease cannot be cured. There are good medical therapies available for both diseases.
What causes Ulcerative Colitis?
The exact cause of IBD is not known but is related to an overactive immune system. This immune system normally turns on and off to fight harmful substances like bacteria and viruses that pass through intestines. In those who develop IBD, the immune system does not turn off once this initial trigger is gone. This leads to uncontrolled inflammation and attack on normal intestinal cells.
The biggest factor associated with IBD is cigarette smoking. Smokers are more likely to develop Crohn’s disease and have a more aggressive form of disease than non-smokers.
Finally, 10-20% of IBD patients have one or more other family members affected with IBD, either Crohn's disease or ulcerative colitis.
What are the symptoms of Ulcerative Colitis?
The most common symptoms seen in ulcerative colitis are diarrhea, rectal bleeding, urgency to have bowel movements, abdominal cramps and pain, fever, and weight loss. In Crohn’s disease, symptoms can result from complications of the disease. Fistulas can lead to openings in the skin and around the anal region that drain stool and infected material. An abscess can lead to symptoms of severe pain and fever. A stricture can lead to intestinal blockage with symptoms of filling up quickly after meals, nausea and vomiting.
In addition, organs other than the intestinal tract can be involved by the underlying inflammation of IBD. These organs include the eyes (symptoms of red eye or blurred vision), the mouth (symptoms of sores in the mouth), joints (symptoms of joint pain with or without joint swelling and redness), and skin (symptoms of rashes or skin ulcers most commonly involving the lower legs).
How is Ulcerative Colitis disease diagnosed?
After discussing your symptoms and doing a physical exam, your doctor may order some additional testing. Blood tests can help detect changes such as low red blood cell counts (anemia), high white blood cell counts (indicate inflammation or infection), and low nutrient levels. Stool samples are sometimes checked to rule out intestinal infections, which can lead to similar symptoms as those of IBD.
The most direct way to make a firm diagnosis of IBD involves the use of endoscopy (using a camera to look the intestines), biopsies, or special X-rays. With endoscopy, the lining of the intestinal tract can be directly seen by the doctor performing the procedure and biopsies can be obtained. Typical changes of IBD can be detected by endoscopy and by examining biopsies under a microscope. Barium X-rays (also known as small bowel series or upper GI studies) are also commonly used to diagnose IBD. Patients drink barium (a white fluid), which allows doctors to take X-ray pictures of the small intestine and to look for changes typical of IBD. This test is particularly helpful in evaluating the small intestine, which cannot be fully examined with endoscopes. Another type of X-ray that is sometimes done in patients with IBD is a CAT scan, which gives a more detailed image than a basic X-ray. Capsule endoscopy is a newer test in which a pill is swallowed and then travels through the small intestine taking pictures that are transmitted to a recorder and later viewed on a computer. Recent studies indicate that capsule endoscopy is more sensitive for Crohn’s in the small intestine than x-rays, but the role of capsule endoscopy in ulcerative colitis is not yet identified.
What medications are available for Ulcerative Colitis?
Crohn’s disease is a chronic illness and often requires long-term treatment with medications. In general there are two main goals of medical therapy for IBD:
Bring active disease under control (into remission)
Keep the disease in remission.
These types of medications are among the most commonly used to treat IBD and include sulfasalazine (Azulfidine®) and mesalamine (Asacol®, Pentasa®, Colazal®). The active component works to reduce inflammation in the intestinal wall. These compounds are prepared differently and based on this release the active ingredient in different parts of the intestinal tract. All the above come as pills taken by mouth but there are also suppository and enema forms of mesalamine that are applied directly into the rectum and used to treat inflammation in the bottom part of the colon.
These medications work well for mild to moderate ulcerative colitis. When effective, they work both to bring active disease under control and to maintain disease in remission. They are generally well tolerated with minimal side effects.
Steroids such as prednisone are commonly used to treat patients with ulcerative colitis. These work as anti-inflammatory agents.The main role of these medications in IBD is to bring the disease into remission. For patients whose disease seems to require repeated or long-term steroid courses, other medical treatment options described below are available and should be considered (see discussion of side effects below). Most commonly these medications are given orally. However, in moderate to severe cases of IBD, patients are brought into the hospital and intravenous steroids are used to bring the disease under control. There are also enema and suppository preparations of steroids available.
There are multiple possible side effects from steroids most of which are more likely to develop with higher doses and longer use. Early side effects can include mood changes, irritability, difficulty sleeping, increased appetite, and increased blood sugar levels. Side effects associated with long-term use include osteoporosis (weakening of the bones), cataracts, acne, development of a fatty hump at the base of the neck, and a rounded/swollen appearance to the face (moon facies). Although there are possible side effects from these types of steroids, they remain an important part of the medical management of inflammatory bowel disease. With appropriate dosing and tapering, most patients tolerate steroids well.
More recently a new steroid preparation named budesonide (Entocort®) has been made available in the United States for treatment of Crohn’s disease. This steroid is specifically designed to treat the intestines with very little of it reaching the bloodstream so there are less side effects when compared to other steroids. This medicine works mostly in treating inflammation in the bottom part of the small intestine (the ileum) and the right part of the colon.
Mercaptopurine and Azathioprine
6-mercaptopurine (Purinethol®) and azathioprine (Imuran®) decrease the activity of the immune system, which then reduces inflammation in the intestines. They used are in Crohn’s disease to bring active disease under control and to keep the disease at bay. They are given orally as pills.
These agents may take a few weeks to months to take their full effect, so other medications such as steroids are sometimes needed on a short-term basis to keep disease under control when starting 6-mercaptopurine or azathioprine. These medications have less long-term side effects than steroids.
Approximately 5-10% of patients cannot tolerate these medications due to side effects such as allergic reactions, pancreatitis (inflammation of the pancreas), and abnormal liver tests. Because these medications affect the immune system, patients have a higher risk of developing infections. Therefore, it is recommended that blood counts be monitored on a frequent and regular basis when on these medications.
When is surgery indicated for Ulcerative Colitis?
For ulcerative colitis, there are two main indications for surgery:
Lack of response or intolerance to medications
Precancerous or cancerous changes in the colon
Patients with ulcerative colitis have a higher risk of developing colon cancer so careful monitoring of the colon by colonoscopy is recommended in those who have had the disease for many years. As previously discussed, surgery allows for a cure in ulcerative colitis. However, removal of the colon used to mean that patients would have to have a permanent colostomy (wearing an external bag to drain stool).
Currently, a procedure known as the pouch procedure can be done in most patients with ulcerative colitis and this prevents the need for a permanent stoma. In this type of surgery, the colon is removed, a reservoir is created out of the lower part of the small intestine (the ileum), and the reservoir is connected to the anal region.