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Ulcerative colitis

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Introduction

Ulcerative colitis is a chronic inflammatory bowel disease that causes ongoing inflammation and ulcers (open sores) in the innermost layers of the large intestine (colon) and rectum. The ulcers bleed and produce pus and mucus, and the inflammation causes the colon to empty frequently, causing diarrhea. Ulcerative colitis is similar to Crohn's disease, another inflammatory bowel disease. But Crohn's disease can happen anywhere in the digestive tract, often in patches, and can spread deeper into tissues. Ulcerative colitis, on the other hand, is usually confined to the innermost layers of tissue and is uniform throughout the colon. Ulcerative colitis can be painful and have life threatening complications.

Ulcerative colitis affects more than 500,000 people in the United States. Although the condition most commonly affects people between the ages of 10 and 20, with a smaller peak at 50 - 80 years of age. Infants and children may also develop the disease. Ulcerative colitis occurs 5 times more frequently in those with a Jewish heritage than it does in the general population. There is no cure for ulcerative colitis, but diet and medications can help control the disease.

Signs and Symptoms

The signs and symptoms of ulcerative colitis vary, depending on how severe the inflammation is and where it is located. The most common include abdominal pain and bloody diarrhea. The symptoms can range from mild to severe. They may come on either very suddenly or more gradually.

Other common symptoms include:

  • Frequent, even continuous diarrhea
  • Rectal bleeding
  • Bloody stool
  • Urgent need to defecate
  • Abdominal cramps and pain
  • Weight loss
  • Anemia
  • Joint aches
  • Fever

People with ulcerative colitis are at increased risk for malnutrition. The condition is also associated with other health problems, including arthritis, eye infections, liver disease, skin rashes, blood clots, or gallstones. No one is sure why such problems occur outside the colon. But some researchers think they may be linked to a faulty immune system response.

What Causes It?

No one knows what causes ulcerative colitis. The most likely theory is that it is caused by several factors ranging from genetics, faulty immune system reactions, and environmental influences. For example, some people are genetically at risk for the condition (it runs in their family). Bacteria or a virus may then trigger their immune system, which causes inflammation. Because ulcerative colitis is more common in the developed world, it's possible that a diet high in saturated fat and processed foods contributes to the disease.

Risk Factors

Risk factors for ulcerative colitis include:

  • Family history of the disease
  • Jewish heritage, especially Ashkenazi (European) Jews
  • A diet high in sugar, cholesterol, and fat (particularly from meat and dairy products)
  • Psoriasis -- Studies show that psoriasis is associated both with Crohn's disease and ulcerative colitis

What to Expect at Your Provider's Office

Your doctor will do a physical exam and a series of tests to diagnose ulcerative colitis. Blood tests may show anemia (due to a significant loss of blood) and a high white blood cell count (a sign of inflammation somewhere in the body). Stool samples may show whether there is bleeding or infection in the colon or rectum.

The following procedures may also help distinguish between ulcerative colitis, Crohn's disease, and other inflammatory conditions.

Colonoscopy and sigmoidoscopy -- In a colonoscopy, a long, flexible, lighted tube with a camera is used to take pictures of the colon. These pictures can reveal any inflammation, bleeding, or ulcers along the entire colon wall. Your doctor may also take a biopsy of colon cells to see whether you have ulcerative colitis or Crohn's disease. The patient is sedated during the procedure. A sigmoidoscopy is similar but is used to examine the rectum and lower part of your colon. It can be done without sedation, but may miss inflammation higher in the colon or the small intestine.

Barium enema -- This test examines the large intestine with an x-ray. You are given barium (a dye) as an enema, which coats the lining of your large intestine and rectum. It is generally not as reliable as colonoscopy and is not used when symptoms are severe because of the risk of complications.

Small intestine x-ray -- In this test, you drink a barium "shake" and the doctor takes an x-ray of your small intestine. This test allows doctors to see the small intestine (which can't be seen with colonoscopy). It can help distinguish between ulcerative colitis and Crohn's disease.

Preventive Care

There is no known way to prevent ulcerative colitis. But you can usually manage the condition with a combination of medication, diet, and lifestyle changes. A low fat diet rich in fruits, fluids, magnesium, and vitamin C; exercise; and stress reduction techniques (including hypnosis) may also help prevent recurrences.

Treatment Options

The primary goal in treating ulcerative colitis is to control acute flares of the disease and to maintain remission. The type of treatment often depends on how severe the disease is. For example, people with mild to moderate ulcerative colitis are usually treated with medications that reduce inflammation and suppress the immune system. More severe cases may require surgery.

Many people with inflammatory bowel diseases use complementary and alternative remedies along with prescription medication. Preliminary studies indicate that lifestyle changes, including stress reduction; dietary adjustments (such as including a rich variety of fruits and vegetables and avoiding saturated fat and sugar); specific herbs and supplements; and mind body techniques (such as hypnosis) may be useful additions to treatment.

Lifestyle

Many people with ulcerative colitis report that stress makes their symptoms worse. Relaxation and stress reduction techniques can be helpful, particularly when used with other forms of treatment. Some techniques to consider:

Biofeedback -- teaches you to control stress related physical responses (muscle tension, rapid heartbeat). First, you use a feedback machine that lets you see how your body responds. As you learn to control these responses, you no longer need the machine and can practice the technique anywhere.

Yoga, tai chi, or meditation -- These techniques all help you learn to reduce your response to stress.

Progressive muscle relaxation -- This popular technique involves tightening and then relaxing specific muscle groups one by one. It is simple to learn and can be done anywhere and any time.

Deep breathing -- Breathing in from your diaphragm (allowing your belly to expand, then contract as you exhale) induces a relaxation response. It may also help relax your abdominal muscles, which can help with normal intestinal health.

Hypnosis -- A trained and licensed hypnotist can help you relax muscle tension, reducing pain and abdominal bloating.

Exercise may help people with ulcerative colitis, both in terms of maintaining health and reducing stress. Although exercise is considered safe for those with ulcerative colitis, anyone with a chronic illness should talk to their doctor before starting a new exercise regimen. It is especially important for people with ulcerative colitis to drink water before and during exercising to prevent dehydration.

Drug Therapies

Although medications cannot cure ulcerative colitis, they can reduce symptoms and help you control your condition. Sometimes, they can bring on remission of the disease for a period of time. Medications commonly used to treat ulcerative colitis include:

Aminosalicylates -- anti-inflammatory drugs used to treat mild to moderate symptoms. About 40 - 80% of patients will respond within 4 weeks to orally administered aminosalicylates. They include:

  • Sulfasalazine (Azulfidine) -- An older drug that is usually taken with folic acid. Side effects include abdominal discomfort, nausea, and lowered sperm count. Sulfasalazine can be effective, but newer drugs are available.
  • Mesalamine (Asacol, Rowasa) -- This drug reduces inflammation during acute flare ups and helps prevent recurrences. It generally has fewer side effects than sulfasalazine.
  • Balsalazide disodium (Colazal) -- A different formulation of mesalamine that is designed to deliver the dose directly into the colon. It has fewer side effects.

Corticosteroids (such as budesonide, prednisone, and prednisolone) -- These drugs can reduce inflammation throughout your body but have many side effects, including acne, and an increased risk of infection, osteoporosis, high blood pressure, excessive hair growth, diabetes, and disorders of the eye including glaucoma and cataracts. Budesonide (Entocort) may have fewer side effects. Corticosteroids also suppress your body's production of the hormone cortisol and cannot be stopped abruptly. They are not for long term use, but may be used to control flares.

Immune system suppressors -- These medications decrease inflammation by suppressing the immune system. They are sometimes used in combination with steroids to reduce the dose of the steroid medication. These drugs can take several months to work, and all may have significant side effects. Drugs include azathioprine (Imuran), mercaptopurine (Purinethol), and cyclosporine.

Biologics -- Infliximab (Remicade) is used to treat moderate to severe symptoms. It keeps a protein produced by immune system from causing inflammation in the body. Other drugs in this class, such as adalimumab (Humira), are being tested.

Nicotine patches -- Researchers aren't sure why, but nicotine patches seem to help some people find short term relief during flares, particularly if the person used to be a smoker. The risks of smoking greatly outweigh any potential benefits, so no one who has ulcerative colitis should start smoking as a treatment.

Antidiarrheal medications (such as diphenoxylate, loperamide, or psyllium) -- Medications that treat diarrhea must be used only under medical supervision and with extreme caution. They can slow down the normal movements of the gastrointestinal tract and, in severe cases, may cause a complication known as toxic megacolon.

Surgical Procedures

About 20 - 30% of people with ulcerative colitis must eventually have their colon or colon and rectum removed (colectomy or proctocolectomy) because of massive bleeding, severe illness, rupture of the colon, or the risk of cancer. The surgery often eliminates the disease. To allow for the elimination of waste, the surgeon creates an internal pouch from the small intestine, which empties into the anus. It may result in having 5 - 7 watery bowel movements a day, and about 32% of people who undergo this procedure develop pouchitis, an inflammation of the pouch that is treated with a short course of antibiotics.

Complementary and Alternative Therapies

Diet

Although diet cannot cure ulcerative colitis, some studies suggest that people who eat foods high in saturated fat and sugar and who eat less amounts of fruits and vegetables may be more at risk of developing the disease. Certain foods may also reduce symptoms.

  • Limit intake of dairy products, which may help reduce diarrhea.
  • Eat fruits and vegetables, and pay attention to fiber. Although fiber is crucial to a healthy diet, some people with inflammatory bowel disease find that fiber makes symptoms worse. If fiber bothers you, steam or bake your vegetables instead of eating them raw, and avoid high fiber foods such as broccoli, cauliflower, and raw apples. Eat antioxidant foods, including fruits (such as blueberries, cherries, and tomatoes) and vegetables (such as squash and bell peppers).
  • A bland, low fiber diet may best during acute flares.
  • Eat 5 - 6 small meals a day.
  • Certain foods may aggravate symptoms of ulcerative colitis (including chocolate, beans, spicy foods, fats, and artificial sweeteners).
  • Avoid refined foods such as white breads and pastas.
  • Avoid caffeine, alcohol, and tobacco.

People with significant malnourishment, severe symptoms, or those awaiting surgery may require parenteral (intravenous) nutrition.

Nutrition and Supplements

Many people with ulcerative colitis have vitamin and mineral deficiencies (because of loss of appetite, reduced absorption by the colon, and chronic diarrhea). Some medications may also lower important nutrients in the body. For example, sulfasalazine reduces the body's ability to absorb folate (folic acid), and corticosteroids can reduce calcium levels. Making sure you get enough nutrients is a crucial part of treating ulcerative colitis. Your doctor may recommend taking a multivitamin daily.

  • Folic acid (800 mcg per day) -- Many people who have ulcerative colitis have low levels of folic acid in their blood. In addition, some medications, such as sulfasalzine, may cause levels of folic acid in the body to drop. People with ulcerative colitis also have a higher risk of developing colon cancer, but some studies have found that taking folic acid can reduce that risk. Folic acid can mask a vitamin B12 deficiency. If you take folic acid for a long period, your doctor should monitor your levels of B12.
  • Omega-3 fatty acids found in fish oil (3.7 g of EPA and 2.2 g of DHA per day) -- At least one study has found that, compared to placebo, fish oil supplements containing omega-3 fatty acids may reduce symptoms and prevent recurrence of ulcerative colitis. Other studies show different results, however. Some experts suggest that omega-3 fatty acids may be valuable when used in combination with sulfasalazine or other medications. Do not take high doses of a fish oil supplement if you take blood thinning medication.
  • Probiotics -- Several studies indicate that taking probiotics, or "good" bacteria, can help reduce symptoms. The types of probiotics studies have varied: Two studies used a non-disease-causing type of E. coli. Another study found that giving Lactobaccillus, Bifidobacteria, and a nondisease causing type of Streptococcus to people with chronic pouchitis helped prevent the condition. Sacchromyces boulardi (250 mg 2 - 3 times per day) may also help generally improve the health of the intestine.
  • Vitamin D (1,000 IU per day) -- is necessary to maintain strong bones. People with ulcerative colitis, especially those who take corticosteroids, often have low levels of vitamin D and are at risk for osteoporosis.
  • Calcium (1,000 - 1,200 mg per day) -- is also needed for strong bones. Ask your doctor if you need a calcium supplement.
  • N-acetyl glucosamine -- Preliminary research suggests that N-acetyl glucosamine supplements or enemas may improve symptoms of inflammatory bowel disease. But more studies are needed to know whether glucosamine would have any effect on ulcerative colitis.

Herbs

Because of the presence of inflammation and the nature of the disease, ulcerative colitis should not be treated with herbs alone. However, herbs may be a useful complement to traditional medical treatment. Remember that herbs can trigger side effects and interact with other herbs, supplements, or medications. For these reasons, you should take herbs with care, under the supervision of a health care provider.

  • Psyllium seeds (Plantaginis ovatae) -- In one study, people with ulcerative colitis who took 20 g of ground psyllium seeds 2 times per day with water stayed in remission as long as when they took the prescription drug mesalamine. Combining the 2 therapies was even more effective. More research is needed to confirm this finding. Psyllium is a type of insoluble fiber, and may be irritating to some people, especially during flares. Talk to your doctor to determine if psyllium can help you. Some people may have better results using soluble fiber, such as flax seed or oat bran, in combination with or instead of psyllium. Constipation could occur, however. Talk to your doctor about whether this combination is right for you.
  • Boswellia (Boswellia serrata, 550 mg 3 times per day for up to 6 weeks) -- Boswellia has anti-inflammatory properties. One small study suggests that people who took boswellia had similar improvement as people who took the prescription drug sulfasalazine. More research is needed to be sure. Boswellia may interact with other drugs and supplements, so talk to your doctor before taking it.
  • Curcumin or turmeric (Curcuma longa, 1 - 2 g per day) -- shows anti-inflammatory properties in test tubes. One small study found that people with inflammatory bowel disease who took curcumin reduce their symptoms and their need for medications. But the study was preliminary, and more evidence is needed.

Other evidence for using herbs to treat ulcerative colitis is mostly lacking. Among the herbs that have been used traditionally to treat inflammation within the digestive tract are:

  • Slippery elm (Ulmus fulva) is a demulcent (protects irritated tissues and promotes their healing); take 60 to 320 mg per day. Mix 1 tsp. powder with water and drink 3 - 4 times a day.
  • Marshmallow (Althaea officinalis) is a demulcent and emollient; drink one cup of tea 3 times per day. To make tea, steep 2 - 5 g of dried leaf or 5 g dried root in one cup boiling water. Strain and cool. Avoid marshmallow if you have diabetes.
  • Chamomile (Matricaria recutita) is often used to soothe digestive tract. It is usually taken as a tea. Dissolve 3 - 4 g powder (about 3 tsp.) in 1 cup hot water, strain, and cool. Drink 3 times per day.

Acupuncture

Acupuncture is often used in Traditional Chinese Medicine to treat inflammatory bowel disease. Several studies indicate that it can provide relief from symptoms in ulcerative colitis. It may be especially useful combined with traditional medical treatment because it can help relieve stress, as well as pain. Acupuncturists treat people with inflammatory bowel disease based on an individualized assessment of the excesses and deficiencies of qi located in various meridians.

Other Considerations

Pregnancy

Symptoms of ulcerative colitis often become worse in pregnancy. About 50% of women in remission have a recurrence of the disease, usually during the first trimester or during the postpartum period. For this reason, women with ulcerative colitis who are or wish to become pregnant should keep taking medications under the guidance of their doctor. Corticosteroids or sulfasalazine are considered safe during pregnancy. Unlike Crohn's disease, pregnant women with ulcerative colitis are not at increased risk for stillbirths or premature deliveries.

Pregnant women should avoid high doses of vitamins. An obstetrician can provide instructions about multivitamin use during pregnancy.

Prognosis and Complications

If left untreated, people with ulcerative colitis can develop a wide range of chronic, sometimes dangerous complications. Fortunately, however, most of these complications can be treated successfully.

  • Hemorrhage (excessive bleeding)
  • Perforation of the colon
  • Narrowing of the colon, which may cause obstruction
  • Abscesses (pus filled pockets of infection) in the colon
  • Toxic megacolon (grossly swollen colon that may rupture)
  • Colon cancer
  • Nutritional problems (including weight loss and reduced muscle mass)
  • Joint pain and arthritis
  • Eye infections/inflammation
  • Mouth ulcers
  • Liver damage
  • Blood clots
  • Depression and anxiety

Although there is no cure for ulcerative colitis other than surgical removal of the colon, many people with the disease lead active lives by controlling their symptoms with medication. In fact, drug treatment is effective for about 70 - 80% of all people with the condition. About 45% of all people with ulcerative colitis are free of symptoms at any given time, but most have at least one relapse in any 10-year period.

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Alternative Names

Inflammatory bowel disease

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