What is Ulcerative Colitis?
Ulcerative colitis is a mystery medical condition that causes inflammation and tiny sores on the wall of the colon, which can lead to bleeding. It’s the most common type of inflammatory bowel disease across the globe. This condition mainly affects the innermost lining of the colon. Usually, the symptoms start in the rectum and gradually spread upwards. In the United States, this condition is responsible for about 250,000 medical appointments each year, and it costs an estimated four billion dollars annually in medical expenses.
Finally, its important to note that ulcerative colitis has no known cure and is a lifelong condition. It deeply affects a person’s physical and mental health.
What Causes Ulcerative Colitis?
The exact cause of inflammatory bowel disease is still unknown. However, it’s believed that genetics might be a key factor. This is because people with a family history of the disease have a higher risk (8% to 14%) of getting it. If you have a close relative with ulcerative colitis, your risk of developing the disease is four times greater. Ulcerative colitis is also more common in Jewish populations compared to other ethnic groups.
Some people believe that changes in the gut bacteria or problems with the immune system that protects the gut could cause ulcerative colitis. There’s also a theory that it could be related to the body’s immune system attacking its own cells.
There’s some suggestion that smoking might actually help protect against the disease, but this link hasn’t been confirmed yet.
Risk Factors and Frequency for Ulcerative Colitis
Inflammatory bowel diseases, which include illnesses like Crohn’s disease and ulcerative colitis, are most common in Northern Europe and North America. These diseases are often associated with a Western lifestyle and environment. Ulcerative colitis, in particular, affects 9 to 20 out of every 100,000 individuals every year. Currently, there are 156 to 291 cases of ulcerative colitis per 100,000 individuals each year. While this condition is more prevalent among adults, in children it’s less common than Crohn’s disease.
- People with ulcerative colitis typically experience their first episode between the ages of 15 and 30. However, there’s a smaller second peak in cases that happens between ages 50 and 70.
- While some studies have found ulcerative colitis to be slightly more common in men, no clear preference has been confirmed.
- If you don’t smoke, or if you quit smoking recently, you may have a higher chance of developing ulcerative colitis. Surprisingly, smokers who get diagnosed with this disease tend to have less severe symptoms and require fewer hospital visits and medications.
- While the evidence isn’t strong, there may be a connection between the use of non-steroidal anti-inflammatory drugs (like ibuprofen) and the beginnings or flare-ups of ulcerative colitis.
There’s also some evidence linking inflammatory bowel disease to the removal of an inflamed appendix at a young age. If you’ve had your inflamed appendix removed before turning 20, you’re less likely to get ulcerative colitis but your chances of getting Crohn’s disease may be higher. Having your appendix removed can decrease the risk of developing ulcerative colitis by 69%.
Signs and Symptoms of Ulcerative Colitis
Ulcerative colitis is a condition that primarily causes bloody diarrhea, often mixed with mucus. Additional symptoms can include a strong urge to use the bathroom, stomach pain, feeling unwell, weight loss, and fever. However, the severity of these experiences can vary greatly based on how much of the colon is inflamed and how intense that inflammation is. Ulcerative colitis usually develops slowly and can cycle between flares and periods of no symptoms. Quitting smoking and using certain anti-inflammatory medications can commonly trigger a flare-up.
Some people with ulcerative colitis also experience symptoms affect areas of the body outside the intestines. These symptoms can correlate to the level of disease activity or they can emerge independently.
- Symptoms related to disease activity include inflammation of the white part of the eye or the outer lining of the eye, joint issues, red bumps on the skin, and painful skin ulcers.
- Symptoms that occur regardless of disease activity include certain types of arthritis affecting the spine and a specific liver disease called primary sclerosing cholangitis (a condition that is linked with an increased risk of developing colorectal cancer).
Testing for Ulcerative Colitis
Ulcerative colitis is primarily diagnosed through clinical examinations, but endoscopy, biopsies, and stool tests for infections can support the diagnosis. Tests for bacterial infections and parasites should be a part of the initial checkup due to the similarity of symptoms with those in colonic infection.
While not critical for the diagnosis, x-ray examinations can provide useful information. Where ulcerative colitis has been present for an extended period, the patient may show a “stove-pipe” sign during a double-contrast barium enema, an X-ray exam using a barium solution for better visibility.
Additional investigations such as a colonoscopy or proctosigmoidoscopy might indicate altered blood vessel patterns, sensitivity, rough texture, and ulceration in the rectum and lower colon. Gradually, this might spread upwards. The severity of the disease can range from being restricted to the rectum (proctitis) to affecting the entire colon (pancolitis). Various population-based studies have shown that proctitis is present in 30%-60% of patients at their first consultation, left-sided colitis in 16%-45%, and pancolitis in 14%-35%.
Typically, lab tests show increased inflammatory indicators (ESR, CRP, leukocytosis), particularly during a flare-up. No matter the condition’s stage, antibodies known as perinuclear antineutrophil cytoplasmic antibodies (P-ANCA) are found in 60%-70% of ulcerative colitis patients. These antibodies may also be present in a minority of individuals with Crohn’s disease. Other markers, such as anti-saccharomyces cerevisiae antibodies (ASCA) and carcinoembryonic antigen (CEA), can further aid the diagnosis, particularly in distinguishing between different types of inflammatory bowel diseases. A fecal calprotectin test, which measures inflammation in the intestines, may also be helpful, although it is not specific to the condition.
The doctor may conduct a colonoscopy, which involves viewing the inner lining of the large intestine for signs like fragile and granular mucosa, changes in vascular pattern, and the presence of erosions. Multiple tissue samples or biopsies should be taken to verify the diagnosis.
Once ulcerative colitis is diagnosed, the Montreal classification system is most commonly used to identify the disease’s extent and severity. The extent can be categorized into Proctitis (E1), left-sided, or distal colitis (E2), and pancolitis (E3) based on endoscopic evaluation. The severity of symptoms, ranging from remission (S0) to severe (S3), is also assigned.
Treatment Options for Ulcerative Colitis
Choosing the best treatment for patients with ulcerative colitis depends on how severe the disease is and how much of their colon it affects. During the first ten years after diagnosis, most people are quite likely to see their symptoms disappear. If the disease affects only the end of the colon, medication can be applied directly to the rectum via suppository or an enema. Often, this local treatment is paired with a systemic (whole body) treatment to help lessen painful bowel movements.
Typically, the first medications tried are sulfasalazine or 5-aminosalicylates, which can be given orally or rectally. About 50% of patients go into remission using these drugs. If symptoms don’t improve within two weeks, glucocorticoids (another type of medication) can be added. With the exception of glucocorticoids, all of these drugs can be used for long-term care to keep patients in remission. Probiotics may also help, and fecal microbiota transplantation has shown some promise in restoring the balance of intestinal bacteria in ulcerative colitis patients.
If glucocorticoids are not effective, two types of drug therapy can be considered. Firstly, thiopurines, a type of immune-suppressing drug, can be used. The second option is biological drugs. These include inflixamab, adalimumab, and golimumab – drugs that target and block certain proteins in the immune system. Inflixamab is most commonly used for ulcerative colitis, particularly in severe cases or hospital admissions. A new group of biological drugs, such as vedolizumab, work by blocking a specific molecule on the surface of certain immune cells.
Future ulcerative colitis treatments could focus on a protein called peroxisome proliferator-activated receptor-gamma (PPAR-gamma), which is less active in ulcerative colitis patients. New versions of 5-aminosalicylic acid (5-ASA) drugs are being developed that could enhance PPAR-gamma activity. However, the existing PPAR-gamma activator drugs can have side effects like heart and metabolism issues, limiting their use.
While surgery to remove the colon can cure ulcerative colitis, it’s often seen as a last resort. Indicators for surgery can include failed medical treatment, severe and sudden colitis, an enlarged and inflamed colon, tears in the intestinal wall, uncontrollable bleeding, side effects from medication, or the presence of pre-cancerous or cancerous cells. The typical procedure involves removing the colon and creating an internal pouch at the end of the small intestine to replace it. If this isn’t possible, an external pouch may be created at the abdomen’s surface.
Because ulcerative colitis increases the risk of colon cancer, regular colonoscopy check-ups are important. To prevent disease relapse, patients will need ongoing treatment, which typically involves aminosalicylate medication, or azathioprine and 6-mercaptopurine for some people.
Although there isn’t a specific diet for ulcerative colitis, many people develop intolerance to lactose. Unlike in Crohn’s disease, special diets or intravenous feeding have no role in ulcerative colitis treatment.
What else can Ulcerative Colitis be?
If someone comes to the doctor with lower belly pain and bloody diarrhea, the doctor may think about these possible problems:
- Crohn’s disease (a type of inflammatory bowel disease)
- A type of inflammation in the colon caused by parasites
- Tuberculosis, an infectious bacterial disease
- Damage to the colon from radiation therapy
- Colon cancer
- Toxic megacolon, a serious complication of certain bowel diseases
- Stomach flu caused by bacteria or viruses
What to expect with Ulcerative Colitis
Ulcerative colitis is a disease that lasts a lifetime. Despite this, the overall death rate is not higher compared to the general population. However, people with ulcerative colitis who experience shock or complications from surgery are at a higher risk of death. If the condition affects the muscular layer of the bowel, it can damage nerves causing the bowel to expand abnormally, lose its ability to move contents along (aperistalsis), and reduced blood flow (ischemia). This leads to a dangerous condition known as toxic megacolon, which has become the most common cause of death in ulcerative colitis patients.
About 5% of people with ulcerative colitis develop colon cancer, and the longer someone has the disease, the higher their risk becomes. It’s worth noting here that unlike Crohn’s disease, the formation of narrowings (strictures) in the bowel is rare in cases of ulcerative colitis.
Possible Complications When Diagnosed with Ulcerative Colitis
Ulcerative colitis is a chronic condition that alternates between periods of calm and flare-ups. This disease can lead to a number of complications, which include:
- Leakage from the surgical connection between two body parts
- Pelvic infection
- An abnormal connection between the intestines and skin
- Slipping or drooping of the pouch created in bowel surgery
- Pouchitis, an inflammation of the pouch, can be acute (lasting less than 4 weeks) or chronic (lasting more than 4 weeks)
- Loss of bowel control
- Problems with sexual function
- Toxic megacolon, a serious condition where the colon becomes dangerously enlarged
- Cancer of the colon or rectum
Preventing Ulcerative Colitis
The American College of Gastroenterology has put together some guidelines to help people with ulcerative colitis take preventative health measures. Their advice includes:
* Getting checked for skin cancer, whether or not you’re using biological treatment methods.
* Having a test to check the strength and health (density) of your bones.
* Making sure you get the vaccine for the Herpes zoster virus.
* Getting your shots for Pneumococcus, H. influenzae, and the flu virus.
* Before traveling to any areas where yellow fever is common, consulting with a disease expert who specializes in infectious diseases.
* Having regular check-ups for depression and anxiety symptoms because mental health is important too.
* For women with ulceric colitis, it’s important to get annual screenings for cervical cancer.
