Ulcerative Colitis

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What is ulcerative colitis?

Ulcerative colitis (UC) is a chronic inflammatory disease of the large intestine, or colon. It occurs when inflammation in the colon produces redness, bleeding and pus, which, in turn, causes such symptoms as diarrhea and abdominal pain. Inflammation impairs the ability of the colon to hold its contents, resulting in frequent elimination. Ulcerative colitis is a type of inflammatory bowel disease, along with Crohn’s disease. The exact cause of ulcerative colitis is not known.

Ulcerative colitis can affect one segment of the colon or the entire colon. Left-side colon involvement is called limited, or distal, colitis. Ulcerative proctitis describes inflammation occurring in the lower part of the colon and rectum. Symptoms range in severity among affected individuals. In a small number of those affected, problems outside of the large intestine may develop, including arthritis, inflammation of the eyes, mouth ulcers, and skin changes. Ulcerative colitis also increases your risk of developing colon cancer.

Ulcerative colitis affects teenagers and young adults, with disease onset usually occurring in peaks between ages 15 and 30, and less commonly between ages 50 and 70. The condition can run in families, with at least 20% of people affected having a family member with the condition. The prevalence of ulcerative colitis is higher in Caucasians and people with Ashkenazi (Eastern European) Jewish ancestry.

Ulcerative colitis itself is not an emergency situation, but serious symptoms may occur. Seek immediate medical care (call 911) for serious symptoms, such as severe abdominal pain, inability to pass gas or stool, and vomiting or vomiting blood.

Seek prompt medical care if you are being treated for ulcerative colitis, but mild symptoms recur or persist.

What are the symptoms of ulcerative colitis?

Symptoms of ulcerative colitis primarily affect the digestive tract and include appetite loss, diarrhea, weight loss, rectal bleeding, nausea, and abdominal cramping. Persistent diarrhea can cause malnutrition, weakness, and electrolyte imbalances; younger individuals may be small or experience delayed growth. A small percentage of those affected may have symptoms in other body areas or organs.

Common symptoms of ulcerative colitis

The most common symptoms of ulcerative colitis are:

  • Bloody stool (blood may be red, black or tarry in texture)
  • Fatigue
  • Low red blood cell count (anemia)
  • Nausea with or without vomiting
  • Nutritional deficiencies
  • Tenesmus (urge to defecate or sense of pressure in rectoanal area)

Extraintestinal symptoms of ulcerative colitis

A small percentage of people who have ulcerative colitis will have symptoms involving other organs or areas of the body including:

  • Mouth ulcers
  • Skin rash or changes

Serious symptoms that might indicate a life-threatening condition

In some cases, ulcerative colitis can produce serious symptoms. Seek immediate medical care (call 911) if you, or someone you are with, have any of these life-threatening symptoms including:

  • Inability to pass gas or stool

What causes ulcerative colitis?

The exact cause of ulcerative colitis (UC) is not known, but the inflammation of ulcerative colitis is thought to be an autoimmune reaction: The immune system, which normally protects us from harmful invaders, starts attacking the body itself. In ulcerative colitis, the immune system seems to attack the lining of the large intestine, creating inflammation and ulcers (sores) and disrupting normal digestion. Genetic and environmental factors may increase (or decrease) the likelihood of immune system malfunction.

Immune system malfunction

One theory is that the immune system mistakenly interprets foods or other substances in the gut as “foreign,” releasing antibodies, white blood cells, and inflammatory factors into the intestines. Another possibility is antigens (proteins) on bacteria and viruses in the gut might falsely trigger ulcerative colitis when the immune system discovers chemically similar molecules on gut cells. But so far, researchers who study UC have not been able to identify any specific bacterial or viral proteins that cause the immune system to target the lining of the colon.

As researchers learn more about the immune system and the gut microbiome (the collection of microscopic organisms that inhabit the digestive system), they may uncover additional information that will help them understand the development and progression of ulcerative colitis.

Abnormal genes

Healthcare providers and patients have noticed ulcerative colitis tends to run in families, so they suspect the disease might be hereditary. Scientists know the disease is most common in white people of European origin, particularly people of Ashkenazi Jewish descent. (People from Ashkenazi Jewish families have approximately a 4.5% lifetime risk of developing ulcerative colitis, compared to a 1.6% lifetime risk for non-Jewish white people.)

These findings strongly suggest abnormal genes, which can be passed down from generation to generation, may be a cause of ulcerative colitis, or at least a contributing factor. However, scientists have not yet been able to identify specific genes or genetic mutations linked to the development of ulcerative colitis. And while 20% of people with ulcerative colitis have a close family member with the disease, the remaining 80% do not. This means abnormal genes and heredity cannot be the only causes of ulcerative colitis.

Environment

Many diseases are caused by a combination of factors. For instance, scientists know certain gene mutations increase a woman’s risk of developing breast cancer. But breast cancer does not develop in all women who have those genetic mutations, so scientists suspect other factors play a role in the development of the disease.

Researchers suspect ulcerative colitis may be the same. Scientists know a high-fat diet may increase the risk of developing ulcerative colitis. Regular intake of nonsteroidal anti-inflammatory drugs (such as aspirin), oral contraceptives, and antibiotics is also associated with an increased risk. Researchers are trying to figure out how these exposures trigger or influence the development of disease.

Years ago, people believed stress could cause ulcerative colitis. Some people do experience symptom flare-ups during periods of high stress, but doctors do not believe emotional distress can cause ulcerative colitis.

Patients and healthcare providers hope continuing research into the causes of ulcerative colitis will eventually point the way toward more effective and more efficient treatments.

What are the risk factors for ulcerative colitis?

A number of factors increase the risk of developing ulcerative colitis. Not all people with risk factors will get ulcerative colitis. Risk factors for ulcerative colitis include:

  • Consumption of excess dietary fats, protein and refined sugar
  • Family history of ulcerative colitis
  • Infection of the intestines
  • Jewish ancestry
  • Quitting smoking (quitting seems to increase the risk of developing UC, possibly due to a protective effect of nicotine against inflammation)
  • Retention of appendix (appendectomy is protective for ulcerative colitis)
  • Use of NSAIDs

Reducing your risk of ulcerative colitis

There is no single cause of ulcerative colitis, which makes it difficult to prevent. Until more is known about its cause, living a healthy life is your best defense, along with:

  • Eating a well-balanced diet low in sugar
  • Getting regular physical exercise

What are some conditions related to ulcerative colitis?

Ulcerative colitis (UC) is one form of inflammatory bowel disease; the other is Crohn’s disease, which can affect any part of the gastrointestinal lining. Like UC, the exact cause of Crohn’s disease is not known. Researchers are investigating possible immune, genetic and environmental triggers of Crohn’s. Pharmaceutical treatment of Crohn’s is similar to ulcerative colitis.

Some people confuse inflammatory bowel disease (IBD) with irritable bowel syndrome (IBS) because the symptoms are similar (and the names are similar too). IBS symptoms include abdominal pain and bloating, along with either constipation or diarrhea. However, IBS does not damage the intestinal lining or appear to involve the immune system. Treatment (medication and self-care) can help control IBS symptoms.

How do doctors diagnose ulcerative colitis?

Doctors suspect a diagnosis of ulcerative colitis (UC) in patients with signs and symptoms of the disease. Diagnosis includes a thorough physical examination and symptom review, along with blood test results, imaging, and endoscopic procedures if necessary.

Signs and symptoms consistent with a UC diagnosis include:

  • Blood in stool, based on stool analysis
  • Fecal incontinence
  • Inflammation, based on high white blood cell count and other inflammatory markers in the blood
  • Inflammation restricted to the large intestine, based on endoscopic procedures, such as colonoscopy, sigmoidoscopy and biopsy. The gastroenterologist performing the biopsy should take samples from throughout the rectum, colon and part of the small intestine to define the extent of inflammation. Inflammation extending into the small intestine may suggest Crohn’s disease rather than UC.

Other diagnostic procedures for ulcerative colitis may include a stool culture, upper endoscopy, or barium enema. These procedures may be performed in order to rule out conditions, such as gastrointestinal infections, which cause some of the same symptoms as UC.

People with severe ulcerative colitis may respond poorly to interventional procedures like colonoscopy, barium enema, and colon cleansing solutions, according to the Crohn’s and Colitis Foundation of America. These procedures may worsen symptoms. If you or a loved one suspects UC or already has a diagnosis, always discuss the benefits and risks of any recommended procedure with the prescribing doctor.

Refining the diagnosis

After the initial diagnosis (or in subsequent follow-ups), the physician determines the severity of the disease—remission, mild, moderate-severe, or fulminant—to decide the most appropriate course of treatment.

The severity of the disease is based on:

  • Extent of inflammation by blood, stool and endoscopic tests
  • Patient-reported outcomes, such as number of bloody stools per day
  • Patient-reported quality of life and ability to function

How is ulcerative colitis treated?

Currently, there is no cure for ulcerative colitis, except by removing the colon. The goal of treatment is to ease the symptoms; remedy the nutritional deficiencies; reduce the number of recurrences, or flare-ups; and improve quality of life and function. Medication and surgery are used to manage the symptoms of ulcerative colitis.

Medications to treat ulcerative colitis include steroids to reduce the inflammation. These are often combined with drugs that suppress the immune response. Immunomodulators are given if aminosalicylates and corticosteroids have failed or have not achieved optimal response.

Medications for ulcerative colitis

The goal of medication is to control inflammation and heal the intestinal lining (mucus membrane)—known as “mucosal healing.”

Medications used to treat ulcerative colitis include:

  • Aminosalicylates, such as sulfasalazine (Azulfidine) and mesalamine (Pentasa, Asacol), which reduce inflammation
  • Antidiarrheals to control diarrhea
  • Biologic agents (anti-TNF infusion therapy) that can rapidly induce remission in patients with severe ulcerative colitis, defined as more than six bloody stool episodes daily
  • Corticosteroids (steroids)
  • Immunomodulators that suppress the body’s immune response, such as azathioprine (Imuran) and 6-mercaptopurine (Purinethol)

After beginning medication therapy, follow-up blood and stool tests for markers of disease activity, such as fecal calprotectin can help monitor the response to various therapies.

Surgery for ulcerative colitis

Surgery is performed in more advanced cases of ulcerative colitis or in patients whose symptoms cannot be controlled by medication. Many people with ulcerative colitis will require colon removal at some point because of damage or to prevent colon cancer. This procedure, known as proctocolectomy, is typically followed by other procedures including:

  • Ileostomy, or creation of an opening in the abdomen called a stoma, which is connected to the ileum of the small intestine. Waste is channeled through the stoma into a colostomy bag, worn over the opening and emptied as needed.
  • Ileoanal anastomosis, which removes the colon and the inside of the rectum but preserves the anus, which is then surgically attached to the ileum. This allows feces to pass out of the body through the anus, avoiding the need for an external waste bag.

Complementary and alternative treatments for ulcerative colitis

Some complementary treatments may help some people in their efforts to deal with ulcerative colitis. These treatments, sometimes referred to as alternative therapies, are used in conjunction with traditional medical treatments. Complementary treatments are not meant to substitute for traditional medical care. Be sure to notify your doctor if you are consuming nutritional supplements or homeopathic (nonprescription) remedies as they may interact with the prescribed medical therapy.

Complementary treatments may include:

  • Massage therapy
  • Nutritional dietary supplements, herbal remedies, tea beverages, and similar products
  • Probiotics, which in one study had a positive effect on symptoms and quality of life as reported by patients with UC
  • Yoga

What are the diet and nutrition tips for ulcerative colitis?

Although specific foods do not cause ulcerative colitis, they can affect your gut and influence your symptoms.

Foods to limit or avoid

Due to their effect on the gastrointestinal lining and digestion, limit or avoid:

  • Alcohol
  • Carbonated drinks
  • Dairy (hard cheese may be OK)
  • High-fiber fruits and vegetables
  • Nuts and seeds, although ground nuts may be OK

Foods to include

You want to avoid foods that can upset your digestion and intestines. Instead, include these items:

  • Low-fiber fruits and those with potassium like bananas and melons
  • Low-fat foods and protein sources like tuna and chicken breast
  • Probiotic-containing food such as yogurt (as long as dairy does not worsen your symptoms)
  • Vitamins and supplements, only as advised by your doctor or a dietitian experienced in helping UC patients

How does ulcerative colitis affect quality of life?

Ulcerative colitis (UC) is a chronic, complex disease that requires much mental, emotional and physical energy to manage. Determinants of quality life include disease symptoms, social and emotional health, sexual functioning, and overall health. People with UC have a lower quality of life compared to a general population (adjusted for age and gender). The more severe the disease, the greater the impact on quality of life.

There is evidence from quality of life studies that people who perceive their UC as more severe and disabling also report greater symptoms of anxiety and depression. This is important as a patient’s outlook is a significant factor in overall functioning and quality of life, especially with chronic diseases.

The greatest impact on quality of life for UC patients is fecal incontinence and other gastrointestinal symptoms. Other factors include:

  • Poor health overall
  • Unemployment
  • Withdrawal from social engagements or group activities

In a Danish study looking at UC quality of life, the most important medical-related attribute to patients was improvement of symptoms within eight weeks. Not surprisingly, there is a preference for oral medications over injections or infusions. Many UC patients who took part in the study noted a preference for not taking steroids, even during a UC flare.

Finding a medication regimen that is both effective and tolerable is an important part of living with UC. Talk to your doctor about your symptoms and experiences with all your prescribed and self-care therapies, such as probiotics or acupuncture. Together, you can determine what works best for you.

What are the potential complications of ulcerative colitis?

Complications of untreated or poorly controlled ulcerative colitis can be serious. You can help minimize your risk of serious complications by following the treatment plan that you and your healthcare professional design specifically for you.

Gastrointestinal complications of ulcerative colitis include:

  • Colon cancer
  • Fissures (tears in the rectum)
  • Intestinal blockage
  • Nutritional deficiencies
  • Skin ulcerations around the anus and colon
  • Toxic megacolon

Other complications of ulcerative colitis include:

  • Arthritis
  • Ocular inflammation

Does ulcerative colitis shorten life expectancy?

With treatment, most people with ulcerative colitis have a good prognosis and normal life expectancy. Still, about one-third to half of people with UC develop more severe disease requiring stronger medications or surgery.

Ulcerative colitis is fatal only in rare cases where serious complications develop, such as colon cancer. If just the rectum and lower colon are involved, the risk of cancer is not higher than normal. But the risk of colon cancer is greater than normal in patients with widespread ulcerative colitis. Treatment can lower the risk of colon cancer.

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Medical Reviewer: William C. Lloyd III, MD, FACS
Last Review Date: 2021 Apr 14
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THIS TOOL DOES NOT PROVIDE MEDICAL ADVICE. It is intended for informational purposes only. It is not a substitute for professional medical advice, diagnosis or treatment. Never ignore professional medical advice in seeking treatment because of something you have read on the site. If you think you may have a medical emergency, immediately call your doctor or dial 911.
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