The Centre for Digestive Diseases

Ulcerative Colitis

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.

Introduction

Ulcerative Colitis is a disease that is characterised by 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 (Backwash Ileitis).

The inflammation is accompanied usually with 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 Crohn's 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. Ulcerative colitis is most likely not an aberrant reaction but an infection.

The most common symptoms of ulcerative colitis are bloody diarrhoea and abdominal pain. Patient's 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, including a combination of the drugs 5-aminosalicylic acids and Sulfasalazine 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 added corticosteroids. Prednisone and Entocort and hydrocortisone are 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.
• Immunosuppressants such as Azathioprine 6-MP and Methotrexate are often used and can make a marked improvement at a low dose with few side effects. Other drugs may be given to relax the patient or to relieve pain, diarrhoea, or infection. Occasionally, symptoms are severe enough that the person must be hospitalized. For example, a person may have severe bleeding or severe diarrhoea that causes dehydration. In such cases the doctor will try to stop diarrhoea 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 many people go on to live more 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 trialling 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. These include VSL#3 and even flora replacement.
• 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 (e.g. infliximab, thalidomide) are currently available for severe cases. Their short term complications need to be considered
• Budesonide. A corticosteroid called budesonide may be nearly as effective as prednisone in treating mild ulcerative colitis, and it has fewer side effects as it is barely absorbed.
• 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.
• 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.