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Ulcerative Colitis
Article provided by the National
Digestive Diseases Information Clearinghouse
On this page:
Causes of ulcerative colitis
Symptoms of ulcerative colitis
Diagnosis of ulcerative colitis
Treatment for ulcerative colitis
Is colon cancer a concern?
Hope Through Research
For More Information on ulcerative colitis
Ulcerative colitis is a disease that causes inflammation and
sores, called ulcers, in the lining of the large intestine. The
inflammation usually occurs in the rectum and lower part of the
colon, but it may affect the entire colon. Ulcerative colitis
rarely affects the small intestine except for the end section,
called the terminal ileum. Ulcerative colitis may also be called
colitis or proctitis.
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The inflammation makes the colon empty frequently, causing
diarrhea. Ulcers form in places where the inflammation has
killed the cells lining the colon; the ulcers bleed and produce
pus.
Ulcerative colitis is an inflammatory bowel disease (IBD), the
general name for diseases that cause inflammation in the small
intestine and colon. Ulcerative colitis can be difficult to
diagnose because its symptoms are similar to other intestinal
disorders and to another type of IBD called Crohn's disease.
Crohn's disease differs from ulcerative colitis because it
causes inflammation deeper within the intestinal wall. Also,
Crohn's disease usually occurs in the small intestine, although
it can also occur in the mouth, esophagus, stomach, duodenum,
large intestine, appendix, and anus.
Ulcerative colitis may occur in people of any age, but most
often it starts between ages 15 and 30, or less frequently
between ages 50 and 70. Children and adolescents sometimes
develop the disease. Ulcerative colitis affects men and women
equally and appears to run in some families.
What causes ulcerative colitis?
Theories about what causes ulcerative colitis abound, but
none have been proven. The most popular theory is that the
body's immune system reacts to a virus or a bacterium by causing
ongoing inflammation in the intestinal wall.
People with ulcerative colitis have abnormalities of the immune
system, but doctors do not know whether these abnormalities are
a cause or a result of the disease. Ulcerative colitis is not
caused by emotional distress or sensitivity to certain foods or
food products, but these factors may trigger symptoms in some
people.
What are the symptoms of ulcerative colitis?
The most common symptoms of ulcerative colitis are abdominal
pain and bloody diarrhea. Patients also may experience
- fatigue
- weight loss
- loss of appetite
- rectal bleeding
- loss of body fluids and nutrients
About half of patients have mild symptoms. Others suffer
frequent fever, bloody diarrhea, nausea, and severe abdominal
cramps. Ulcerative colitis may also cause problems such as
arthritis, inflammation of the eye, liver disease (hepatitis,
cirrhosis, and primary sclerosing cholangitis), osteoporosis,
skin rashes, and anemia. No one knows for sure why problems
occur outside the colon. Scientists think these complications
may occur when the immune system triggers inflammation in other
parts of the body. Some of these problems go away when the
colitis is treated.
How is ulcerative colitis diagnosed?
A thorough physical exam and a series of tests may be required
to diagnose ulcerative colitis.
Blood tests may be done to check for anemia, which could
indicate bleeding in the colon or rectum. Blood tests may also
uncover a high white blood cell count, which is a sign of
inflammation somewhere in the body. By testing a stool sample,
the doctor can detect bleeding or infection in the colon or
rectum.
The doctor may do a colonoscopy or sigmoidoscopy. For either
test, the doctor inserts an endoscope--a long, flexible, lighted
tube connected to a computer and TV monitor--into the anus to
see the inside of the colon and rectum. The doctor will be able
to see any inflammation, bleeding, or ulcers on the colon wall.
During the exam, the doctor may do a biopsy, which involves
taking a sample of tissue from the lining of the colon to view
with a microscope. A barium enema x ray of the colon may also be
required. This procedure involves filling the colon with barium,
a chalky white solution. The barium shows up white on x ray
film, allowing the doctor a clear view of the colon, including
any ulcers or other abnormalities that might be there.
What is the treatment for ulcerative colitis?
Treatment for ulcerative colitis depends on the seriousness of
the disease. Most people are treated with medication. In severe
cases, a patient may need surgery to remove the diseased colon.
Surgery is the only cure for ulcerative colitis.
Some people whose symptoms are triggered by certain foods are
able to control the symptoms by avoiding foods that upset their
intestines, like highly seasoned foods, raw fruits and
vegetables, or milk sugar (lactose). Each person may experience
ulcerative colitis differently, so treatment is adjusted for
each individual. Emotional and psychological support is
important.
Some people have remissions--periods when the symptoms go
away--that last for months or even years. However, most
patients' symptoms eventually return. This changing pattern of
the disease means one cannot always tell when a treatment has
helped.
Some people with ulcerative colitis may need medical care for
some time, with regular doctor visits to monitor the condition.
Drug Therapy
The goal of therapy is to induce and maintain remission, and to
improve the quality of life for people with ulcerative colitis.
Several types of drugs are available.
- Aminosalicylates, drugs that contain 5-aminosalicyclic acid
(5-ASA), help control inflammation. Sulfasalazine is a
combination of sulfapyridine and 5-ASA and is used to induce and
maintain remission. The sulfapyridine component carries the
anti-inflammatory 5-ASA to the intestine. However, sulfapyridine
may lead to side effects such as include nausea, vomiting,
heartburn, diarrhea, and headache. Other 5-ASA agents such as
olsalazine, mesalamine, and balsalazide, have a different
carrier, offer fewer side effects, and may be used by people who
cannot take sulfasalazine. 5-ASAs are given orally, through an
enema, or in a suppository, depending on the location of the
inflammation in the colon. Most people with mild or moderate
ulcerative colitis are treated with this group of drugs first.
- Corticosteroids such as prednisone and hydrocortisone also
reduce inflammation. They may be used by people who have
moderate to severe ulcerative colitis or who do not respond to
5-ASA drugs. Corticosteroids, also known as steroids, can be
given orally, intravenously, through an enema, or in a
suppository, depending on the location of the inflammation.
These drugs can cause side effects such as weight gain, acne,
facial hair, hypertension, mood swings, and an increased risk of
infection. For this reason, they are not recommended for
long-term use.
- Immunomodulators such as azathioprine and 6-mercapto-purine
(6-MP) reduce inflammation by affecting the immune system. They
are used for patients who have not responded to 5-ASAs or
corticosteroids or who are dependent on corticosteroids.
However, immunomodulators are slow-acting and may take up to 6
months before the full benefit is seen. Patients taking these
drugs are monitored for complications including pancreatitis and
hepatitis, a reduced white blood cell count, and an increased
risk of infection. Cyclosporine A may be used with 6-MP or
azathioprine to treat active, severe ulcerative colitis in
people who do not respond to intravenous corticosteroids.
Other drugs may be given to relax the patient or to relieve
pain, diarrhea, or infection. Hospitalization
Occasionally, symptoms are severe enough that the person must be
hospitalized. For example, a person may have severe bleeding or
severe diarrhea that causes dehydration. In such cases the
doctor will try to stop diarrhea and loss of blood, fluids, and
mineral salts. The patient may need a special diet, feeding
through a vein, medications, or sometimes surgery.
Surgery
About 25 percent to 40 percent of ulcerative colitis patients
must eventually have their colons removed because of massive
bleeding, severe illness, rupture of the colon, or risk of
cancer. Sometimes the doctor will recommend removing the colon
if medical treatment fails or if the side effects of
corticosteroids or other drugs threaten the patient's health.
Surgery to remove the colon and rectum, known as proctocolectomy,
is followed by one of the following:
- Ileostomy, in which the surgeon creates a small opening in the
abdomen, called a stoma, and attaches the end of the small
intestine, called the ileum, to it. Waste will travel through
the small intestine and exit the body through the stoma. The
stoma is about the size of a quarter and is usually located in
the lower right part of the abdomen near the beltline. A pouch
is worn over the opening to collect waste, and the patient
empties the pouch as needed.
- Ileoanal anastomosis, or pull-through operation, which allows
the patient to have normal bowel movements because it preserves
part of the anus. In this operation, the surgeon removes the
diseased part of the colon and the inside of the rectum, leaving
the outer muscles of the rectum. The surgeon then attaches the
ileum to the inside of the rectum and the anus, creating a
pouch. Waste is stored in the pouch and passed through the anus
in the usual manner. Bowel movements may be more frequent and
watery than before the procedure. Inflammation of the pouch (pouchitis)
is a possible complication.
Not every operation is appropriate for every person. Which
surgery to have depends on the severity of the disease and the
patient's needs, expectations, and lifestyle. People faced with
this decision should get as much information as possible by
talking to their doctors, to nurses who work with colon surgery
patients (enterostomal therapists), and to other colon surgery
patients. Patient advocacy organizations can direct people to
support groups and other information resources. (See For More
Information for the names of such organizations.)
Most people with ulcerative colitis will never need to have
surgery. If surgery does become necessary, however, some people
find comfort in knowing that after the surgery, the colitis is
cured and most people go on to live normal, active lives.
Research
Researchers are always looking for new treatments for ulcerative
colitis. Therapies that are being tested for usefulness in
treating the disease include
- Biologic agents. These include monoclonal antibodies,
interferons, and other molecules made by living organisms.
Researchers modify these drugs to act specifically but with
decreased side effects, and are studying their effects in people
with ulcerative colitis.
- Budesonide. This corticosteroid may be nearly as effective as
prednisone in treating mild ulcerative colitis, and it has fewer
side effects.
- Heparin. Researchers are examining whether the anticoagulant
heparin can help control colitis.
- Nicotine. In an early study, symptoms improved in some patients
who were given nicotine through a patch or an enema. (This use
of nicotine is still experimental--the findings do not mean that
people should go out and buy nicotine patches or start smoking.)
- Omega-3 fatty acids. These compounds, naturally found in fish
oils, may benefit people with ulcerative colitis by interfering
with the inflammatory process.
Is colon cancer a concern?
About 5 percent of people with ulcerative colitis develop colon
cancer. The risk of cancer increases with the duration and the
extent of involvement of the colon. For example, if only the
lower colon and rectum are involved, the risk of cancer is no
higher than normal. However, if the entire colon is involved,
the risk of cancer may be as much as 32 times the normal rate.
Sometimes precancerous changes occur in the cells lining the
colon. These changes are called "dysplasia." People who have
dysplasia are more likely to develop cancer than those who do
not. Doctors look for signs of dysplasia when doing a
colonoscopy or sigmoidoscopy and when examining tissue removed
during the test.
According to the 2002 updated guidelines for colon cancer
screening, people who have had IBD throughout their colon for at
least 8 years and those who have had IBD in only the left colon
for 12 to 15 years should have a colonoscopy with biopsies every
1 to 2 years to check for dysplasia. Such screening has not been
proven to reduce the risk of colon cancer, but it may help
identify cancer early should it develop. These guidelines were
produced by an independent expert panel and endorsed by numerous
organizations, including the American Cancer Society, the
American College of Gastroenterology, the American Society of
Colon and Rectal Surgeons, and the Crohn's & Colitis Foundation
of America Inc., among others.
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