Inflammatory Bowel Disease
Inflammatory bowel disease (IBD) is characterised
by chronic intestinal inflammation. The two major types
of IBD are Crohn's disease and ulcerative colitis, although
other less common IBD conditions are also included in this
category.
Ulcerative Colitis
Introduction
Ulcerative colitis is a disease that causes
inflammation and micro-ulcers in the superficial layers
of the large intestine. The inflammation usually occurs
in the rectum and lower part of the colon, but it may affect
the entire large intestine (pancolitis). Ulcerative colitis
can very rarely affect the small intestine in its distal
portion (ileum).
The inflammation causes diarrhoea, which may
be profuse and bloody. Micro-ulcers form in places where
inflammation has destroyed the cells lining the bowel and
these areas bleed and produce pus and mucus. Ulcerative
colitis, especially when mild, can be difficult to diagnose
because symptoms are similar to other intestinal disorders,
most notably the other type of IBD called Crohn's disease
and also irritable bowel syndrome. Crohn's disease differs
from ulcerative colitis because it causes inflammation throughout
the whole thickness of the intestinal wall and produces
deep ulcers. Crohn's disease usually occurs in the small
intestine, but it can also occur in the large intestine,
anus, oesophagus, stomach, appendix and mouth. Crohn's disease
causes fistulae whereas ulcerative colitis does not. Both
Crohns and ulcerative colitis may co-exist in the same patient.
Ulcerative colitis occurs most often in people
ages 15 to 30, although the disease may afflict people of
any age. It affects men and women equally and appears to
run in some families. Unlike Crohn's disease, cigarette
smoking appears to decrease the risk of developing ulcerative
colitis.
Causes and Symptoms
The cause of ulcerative colitis is unknown.
There is some evidence to suggest that the body's immune
system reacts to an environmental, dietary or infectious
agent in genetically susceptible individuals causing inflammation
in the intestinal wall. The latest postulated causal agent
is said to be an infection of the lining with a Fusobacterium
varium identified by researchers from Japan. 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.
The most common symptoms of ulcerative colitis
are bloody diarrhoea and abdominal pain. Patients also may
experience fever, rectal bleeding, fatigue, anaemia, loss
of appetite, weight loss and loss of body fluids and nutrients
resulting in nutritional deficiencies. These symptoms occur
as intermittent attacks in between periods when the symptoms
go away (remissions). These disease-free periods can last
for months or even years. Usually an attack begins with
increased urgency to defecate, mild lower abdominal cramps,
and blood and mucus in the stools.
Ulcerative colitis may cause long-term problems
such as arthritis, inflammation of the eye, liver disease
(fatty liver, hepatitis, cirrhosis, and primary sclerosing
cholangitis), osteoporosis, skin rashes, anaemia and kidney
stones. These complications may occur when the immune system
triggers inflammation in other parts of the body. These
problems can disappear when the colitis is treated effectively.
Diagnosis  
Ulcerative colitis can be difficult to diagnose
because symptoms are similar to other intestinal disorders,
most notably Crohn's disease and irritable bowel syndrome.
Ulcerative colitis differs from Crohn's disease in that
the inflammation is confined to the upper layers of the
intestinal lining, whereas Crohn's causes inflammation throughout
the whole thickness of the intestinal wall.
A thorough physical exam and a series of tests
may be required to diagnose ulcerative colitis. Blood tests
may be performed to check for anaemia, 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
or infection. By testing a stool sample, the doctor can
tell if there is a specific bacterial, parasitic infection
or bleeding in the intestine.
The doctor may do a colonoscopy. For this
test, the doctor inserts an endoscope - a long, flexible,
tube equipped with a miniature camera and biopsy instruments
- into the anus to view the inside of the colon and rectum.
Inflammation, bleeding, or ulcers on the colon wall can
be visualised. The doctor may take a biopsy, which is a
sample of tissue from the lining of the colon, to examine
under a microscope. A barium enema x-ray of the colon may
also be required. This procedure involves the patient swallowing
barium, a chalky white solution. The barium shows up white
on x-ray film, allowing ulcers or other abnormality to be
seen.
Treatment
Treatment for ulcerative colitis depends on
the seriousness of the disease. Most people are treated
with medication. 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 or dairy products. Each person may experience ulcerative
colitis differently, so treatment is adjusted for each individual.
Emotional and psychological support is also important. Patients
with ulcerative colitis may need medical care for some time,
with regular visits to the doctor to monitor the condition.
-
Drug Therapy Most patients with mild or moderate
disease are first treated with 5-ASA agents, which are
a combination of the drugs sulfonamide, sulfapyridine,
and salicylate that helps control inflammation. Sulfasalazine
is the most commonly used of these drugs. Sulfasalazine
can be used for as long as needed and can be given along
with other drugs. Patients who do not do well on sulfasalazine
may respond to newer 5-ASA agents. Possible side effects
of 5-ASA preparations include nausea, vomiting, heartburn,
diarrhoea and headache.
People with severe disease and those who do not respond
to 5-ASA preparations may be treated with corticosteroids.
Prednisone and hydrocortisone are two corticosteroids
used to reduce inflammation. They can be given orally,
intravenously, through an enema, or in a suppository,
depending on the location of the inflammation. Corticosteroids
can cause side effects such as weight gain, acne, facial
hair, hypertension, diabetes, mood swings, and increased
risk of infection, so doctors carefully monitor patients
taking these medications.
Other drugs may be given to relax the patient or to relieve
pain, diarrhea, or infection. 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
In severe cases, a patient may need surgery to remove the
diseased colon. 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. Most people with ulcerative colitis will never need
to have surgery. If surgery ever does become necessary,
however, some people find comfort in knowing that after
the surgery, the colitis segment is removed and most people
go on to live normal, active lives.
Research
Researchers are always looking for new treatments
for ulcerative colitis. Several drugs are being tested
to see whether they might be useful in treating the disease:
-
Probiotics. Researchers at the
Centre for Digestive Diseases have been trialing the
use of living organisms to treat ulcerative colitis
on the basis of restoring the balance of healthy bacteria
in the bowel. Our results are at the forefront of
world research in this field and may eventually provide
a valuable alternative to the current immunosuppressant
medications with the added benefit of no side effects.
-
Anti-TNF. Tumour necrosis factor is a protein
produced by the body's immune system that is thought
to contribute to the inflammation seen in ulcerative
colitis. Drugs with anti-TNF properties (eg. infliximab,
thalidomide) are currently undergoing investigation
as possible treatments for inflammatory bowel disease.
-
Budesonide. A corticosteroid called budesonide
may be nearly as effective as prednisone in treating
mild ulcerative colitis, and it has fewer side effects.
-
Cyclosporine. Cyclosporine, a drug that suppresses
the immune system, may be a promising treatment for
people who do not respond to 5-ASA preparations or
corticosteroids.
-
Nicotine. In an early study, symptoms improved
in some patients who were given nicotine through a patch
or an enema. (Using nicotine as treatment is still experimental
- these findings do not mean that doctors recommend
that patients start smoking!)
-
Heparin. Researchers overseas are examining
whether this anticoagulant can help control ulcerative
colitis by preventing blood clots.
-
NAG - (N-Acetyl Glucosamine) is a nutritional
supplement which has been found to have both anti inflammatory
effect in the bowel as well as in joints. There are
only successful case reports and no blinded trial reports
as yet. The major advantage of NAG is that it is so
free of adverse effects.
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