Ulcerative Colitis

Ulcerative colitis affects people worldwide, most of whom are diagnosed with an inflammatory bowel disease before the age of 35. Ulcerative colitis primarily affects the large intestine. It is characterized by the inflammation of the lining of the colon and the rectum, which together form the large intestine. It begins in the rectum and the lower part of the colon. It is a lifelong condition which can be treated and managed but not cured.

Ulcerative colitis is a form of inflammatory bowel disease (IBD) which should not be confused with irritable bowel syndrome (IBS) or Crohn’s disease.

• Irritable bowel syndrome is a far more common disorder which causes discomfort and symptoms like mild but recurring abdominal pain, bloating and constipation. However, in ulcerative colitis, the inflammation of the large intestine leads to sores and ulcers.
• Crohn’s disease which can affect any part of the digestive tract. While ulcerative colitis mainly affects the lower part of the large intestine (the rectum). However, in some people it may affect the entire colon. 

Based on the areas of inflammation, ulcerative colitis can be of four types.

• Ulcerative Proctitis
  In this form of ulcerative colitis, the inflammation is limited to the rectum. Ulcerative proctitis is a milder form of ulcerative colitis and has fewer complications.
• Proctosigmoiditis
  This form of colitis affects the rectum and the lower part of the colon, which is located right above the rectum.
• Left-sided colitis
  In left-sided colitis, the inflammation begins at the rectum and extends until the bend in the colon near the spleen.
• Total colitis
  Also known as the pan-ulcerative colitis, this form affects the entire length of the colon. The symptoms are severe, and the risk of developing complications is also high.

There are some characteristic symptoms of ulcerative colitis which may be sometimes mistaken for indigestion. The most common symptoms include:

• Diarrhoea with blood or pus.
• Nausea.
• Loss of appetite
• Weight loss.
• Fatigue.
• Abdominal pain.
• An urgent need to empty the bowel.

There are a few symptoms which are less common but are reported in those with ulcerative colitis. These symptoms are usually accompanied by the more common symptoms. The less common symptoms are mostly experienced during a flare-up (when the symptoms are suddenly too intense). These less common symptoms include:

• Joint pain
• Sore muscles. (Read more - Muscle pain treatment)
• Mouth ulcers.
• Irritation in the eyes.
• Rashes.

In severe cases where there are six or more bowel movements in a day, additional symptoms may be seen such as:

• Difficulty in breathing.
• Fever.
• Dehydration.
• Palpitations (fast and irregular heartbeat).
• Blood in stool.

The exact cause of ulcerative colitis remains unknown. Most medical practitioners claim it to be a result of a problem with the immune system.

Causes

These include:

• Genetics
  Studies report that more than one in four people suffering from ulcerative colitis have a family history of the condition. Research studies have also pointed out the presence of certain abnormal genes, which are present in people with ulcerative colitis.
• Overactive immune system
  Researchers believe that an abnormal immune reaction in the intestine may be one cause of ulcerative colitis. Presence of certain bacteria or viruses may trigger an immune response, which attacks the inner lining of the large intestine. The immune response then leads to inflammation which gives rise to the symptoms.
• Environmental factors
  Environmental factors such as stress and an intake of certain medications can also cause ulcerative colitis.

Risk Factors

As previously stated, the exact cause of ulcerative colitis remains unknown. Hence, the suspected causes also tend to be the risk factors of the condition.

• Ulcerative colitis can occur in people of any age group. However, certain people may be at a higher risk of developing it. It is more likely to develop in people who:
  • Belong to the age group of 15-30 years.
  • Are older than 60 years,
  • Have a family history of an inflammatory bowel disease.
• Non-steroidal anti-inflammatory (NSAIDs) drugs, antibiotics, and oral contraceptives may also increase the risk of developing ulcerative colitis.
• Emotional stress or environmental stress may not necessarily increase the risk of developing ulcerative colitis, but, may trigger a flare-up and aggravate the symptoms.
• Strangely enough, studies show that countries with developed sanitation systems have a higher ratio of people suffering from ulcerative colitis.

Since ulcerative colitis can stem from genetic causes and immune system related factors, the prevention of ulcerative colitis is not entirely possible. However, the symptoms can be managed to reduce the discomfort.

In order to diagnose a person with ulcerative colitis, several tests may be performed. These include:

• Medical and family history
  The doctor will inquire about your medical history and overall health to understand the symptoms. Family history also provides important information regarding the severity of the condition and measures that can be taken to control the symptoms. While explaining the symptoms, it is important that you describe them clearly and specify the time duration for which they have been occurring.
• Physical examination
  During a physical examination for diagnosing ulcerative colitis, the doctor will check for any abdominal distension or swelling. If you experience any pain or tenderness in the abdominal region, then you must inform the doctor about it.
• Laboratory tests
  Laboratory tests such as blood and stool tests are the most common diagnostic tools for diagnosing ulcerative colitis
  • A blood test can help to determine conditions like anaemia, inflammation, any signs of infection, low albumin levels, and low protein levels as commonly seen in people with advanced ulcerative colitis.
  • A stool test may also be carried out. The stool sample provides significant information and can help in detecting infection or any other gastrointestinal disease.
• Endoscopy
  Endoscopy of the large intestine is the most accurate way of diagnosing ulcerative colitis. An endoscopy can also be helpful in ruling out other conditions such as Crohn’s disease or cancer. There are two kinds of endoscopy of the large intestine that are carried out for diagnostic purposes.
• Colonoscopy
  A colonoscopy involves the use of a narrow tube fitted with a tiny camera on one end. This helps the doctor to take a look inside the colon. The doctor is then able to examine the tissues lining the colon and the rectum. A colonoscopy helps to detect any swollen tissues, inflammation, or any abnormal growths such as polyps (pieces of tissue growing on the inner lining of the intestine). If the doctor suspects ulcerative colitis, then a biopsy may be needed for confirmation.
• Flexible Sigmoidoscopy
  This test makes use of a flexible and narrow tube with an attached camera on one end. The tube is known as the sigmoidoscope. It allows the doctor to have a video image of the rectum, the sigmoid colon, and the descending colon. The person may be asked to move several times during the procedure to get a better view. Sigmoidoscopy also helps in detecting swelling, polyps, and ulcers. For both colonoscopy and flexible sigmoidoscopy, specific instructions will be provided by the doctor about how to prepare for the procedures and how to take care of oneself after the procedure.
• Other diagnostic tests 
  These include diagnostic tests such as magnetic resonance imaging (MRI) and computed tomography (CT scan).

Although there is no cure for ulcerative colitis, the aim of the treatment is to help the people regulate their immune system better. Ulcerative colitis can affect a person’s quality of life. A combination of treatment modalities can help in reducing the flare-ups and controlling the symptoms.

Medication

Medications prescribed for the treatment of ulcerative colitis work by reducing inflammation of the colon and letting the tissues heal naturally. Other symptoms like frequent bowel movements, pain, and bleeding can also be suppressed with medications. The medicines can help in reducing the number of flare-ups which will give time to the intestine to heal naturally. The medications not only induce and maintain remission but also help in improving the quality of the life in these people.

These medications include:

• Aminosalicylates
  These are medications which help in controlling inflammation. They are prescribed to people with mild to moderate symptoms. Aminosalicylates are oral medications and are well tolerated.
• Corticosteroids
  Corticosteroids work by reducing the activity of the immune system and reducing inflammation. These are usually prescribed to people with severe symptoms. They are meant for long-term use and can have a few side-effects like acne, weight gain, and mood swings.
• Immuno-modulators
  These are only prescribed to people who do not respond to any other form of medication. Immuno-modulators suppress the immune system and reduce inflammation. These medications come with an added risk of infection and slightly increased risk of skin cancers. Hence, these can only be taken after proper medical consultation.
• Biologics
  Biologics also target the immune system and suppress its activity in order to reduce inflammation.

Medications may be administered depending upon the area of the large intestine in which the symptoms are occurring. The medications may be administered as:

• Enema (by flushing liquid medication into the rectum).
• Rectal foam.
• Suppository (inserting a solid and dissolvable medication into the rectum).
• IV or intravenous (administration through the veins).
• Some medications can be taken orally as well.

Combination therapy

Simultaneous use of two therapies to get effective results and manage the symptoms better is known as a combination therapy. However, a combination therapy is not widely prescribed since it has a few associated side-effects and could also reduce the effectiveness of the previous medications.

Surgery

• People in whom the drug therapy is showing no improvement and complications have started, surgery may be recommended. Surgery involves removing the entire colon including the rectum to get rid of the symptoms entirely. There are different kinds of surgery for ulcerative colitis. The first one involves the removal of the entire colon and the rectum, along with, the creation of an opening on the abdomen through which the wastes are emptied into a pouch. This pouch is attached to the abdominal skin using an adhesive.
• The other surgical option also removes the colon but involves the creation of an internal pouch which is attached to the anal sphincter muscle. Recovery from both the procedures can take 4-6 weeks.

Lifestyle management

Nutrition is important in the management of ulcerative colitis. Changes in the diet can help in managing the symptoms and reducing the flare-ups as well. Some recommended dietary changes include:

• Avoiding sodas and carbonated beverages.
• Consuming more fluids such as water and fruit juices.
• Avoiding high fibre foods such as nuts and vegetable skins.
• Avoiding spicy food.
• Avoiding regular painkillers.
• Eating small meals throughout the day instead of large meals.

In case of poor absorption of nutrients from the intestine, there are a few supplements which one can take after consulting the doctor. Depending on the symptoms, the following dietary recommendations may be made:

• Low-salt diet.
• Low-fibre diet.
• Low-fat diet.
• Lactose-free diet.
• High-calorie diet.

It is very important to maintain a healthy diet, which has been planned according to a person’s symptoms. Hence, it is necessary to consult the doctor regarding the foods one must or must not consume.

It is recommended that a person with ulcerative colitis must undergo a colonoscopy every one to three years (once a year or once every 3 years, as recommended by the doctor).

Prognosis

Ulcerative colitis is an unpleasant disease to deal with and can have a significant impact on the individual’s lifestyle. The longer the person suffers from the disease, the higher is the risk of complications. Long-term presence of ulcerative colitis also increases the risk of developing colon cancer. Hence, the course of treatment for ulcerative colitis has to be carefully chosen. During the treatment or even after surgery, regular check-ups are essential.

Complications

Complications arising from ulcerative colitis include:

• Rectal bleeding
  The ulcers present in the intestine may open and bleed. Rectal bleeding can also cause anaemia. Individuals suffering from severe bleeding may require surgery to prevent further complications.
• Dehydration
  When the large intestine is unable to absorb fluids and nutrients, the individual may suffer from dehydration and malabsorption.
• Bone changes
  Bone changes such as osteoporosis (loss of bone) and osteopenia (decrease in bone density) may result from an intake of steroidal medications.
• Megacolon
  Megacolon is a life-threatening complication which may arise when the deep tissue layers of the large intestine get damaged and the intestine stops functioning. Although this is a rare complication, it still needs to be looked out for.