What is ulcerative colitis?
Ulcerative colitis is a type of inflammatory bowel disease (IBD). Crohn’s disease also belongs to this group of diseases. Both diseases cause diarrhea (sometimes bloody stools) and abdominal pain, and the symptoms are so similar that it is sometimes difficult, even for doctors, to make a definitive diagnosis. In fact, in about 10% of cases, it is not possible to distinguish between ulcerative colitis and Crohn’s disease.
While Crohn’s disease may affect all parts of the digestive tract, ulcerative colitis is often limited to the colon (also known as the large intestine). The inflammation usually begins in the rectum and gradually spreads throughout the colon. Ulcerative colitis lesions have no normal intestinal tissue between segments of the bowel, while Crohn’s disease is often a jumpy lesion. Crohn’s disease can involve the entire intestinal wall, whereas ulcerative colitis involves only the innermost layer of the intestinal wall, causing an inflammatory response with the formation of tiny foci of erosion or ulcers that lead to bleeding, pus, and mucus. In a nutshell, ulcerative colitis is an inflammatory disease of the inner lining of the colon.
The more you know, the more comfortable you will be with the disease.
What does “chronic” mean?
No one knows exactly what causes ulcerative colitis or Crohn’s disease. No one can predict how the disease will affect a person once it is diagnosed. Some people may remain unscathed for years, while others have frequent flare-ups. But one thing is clear: Ulcerative colitis, like Crohn’s disease, is a chronic disease.
Chronic diseases are a state of continuous progression. They can be managed with treatment, but they cannot be cured. This means that the disease is long-term, but it does not mean that it is fatal. This is important! Most people with ulcerative colitis lead equally full and colorful lives.
Introduction to the digestive tract.
Most of us are probably not familiar with the composition of the human digestive tract and its respective roles, even though it is an important part of the body. The following is a brief description.
The entire digestive tract begins in the mouth, followed by a long and curved section, and finally reaches the rectum. In between there are many digestive organs that play a role in passing and digesting and absorbing food.
First is the esophagus, a long, narrow tube that connects the mouth to the stomach. Below the esophagus follows the stomach, small intestine, colon (large intestine), and rectum.
The main role of the colon is to absorb the water and salts remaining in the food that has been digested by the small intestine, and it also stores the solid residue so that it becomes feces and is eventually expelled through the anus.
The inflammation in ulcerative colitis usually originates in the rectum and the lower colon, but it can also involve the entire colon. Ulcerative colitis may also be named accordingly depending on the site of the lesion as follows
Ulcerative proctitis: involving only the rectum.
rectosigmoiditis: involving the rectum and sigmoid colon (low colon, located above the rectum)
distal colitis: involving only the left hemicolectum
Total colitis: involves the entire colon.
Who is at risk for ulcerative colitis?
About 1.4 million Americans have either ulcerative colitis or Crohn’s disease. The number of people with each disease is about 50/50. The following is a concise set of data.
Approximately 30,000 new patients are diagnosed with Crohn’s disease and ulcerative colitis each year; ulcerative colitis can occur at any age; on average, ulcerative colitis occurs around age 35; men in their 50s and 60s are more likely to develop ulcerative colitis than women; Caucasians are more likely to develop ulcerative colitis than people of other races; the disease also occurs more often in people of Jewish origin (mostly of Eastern European descent ); both ulcerative colitis and Crohn’s disease are more prevalent in developed countries, more urban than rural, and more northern than southern cities.
Genetic factors.
Studies have found that ulcerative colitis is prone to occur in certain specific families.
In fact, about 20% of people with ulcerative colitis have first-degree relatives (i.e., cousins/sisters or closer) who also have ulcerative colitis or Crohn’s disease. Genetic factors therefore play a role, although there is no definitive evidence as to how genetics play a role. This means that there is no way to predict which family members are susceptible to ulcerative colitis or Crohn’s disease.
What causes ulcerative colitis?
As we described earlier, no one knows the exact cause of the onset of the disease. But one thing is clear: it is not something you did that caused you to get ulcerative colitis. It’s not something you caught from someone else, it’s not something you smoked or drank, and a stressful lifestyle didn’t give you the disease. So, don’t blame yourself!
So, what are the possible factors? Most experts consider it to be multifactorial, meaning that it takes a combination of internal and external factors to cause ulcerative colitis – including the following three possible factors.
Genetic factors; inappropriate immune response of the body; and certain factors in the environment.
This is a monogenic or polygenic disease. Certain triggers in the environment may cause a series of reactions that eventually lead to the development of the disease. Whatever the cause, it activates the body’s immune system, which combats external invaders, and this is where the inflammation begins. Unfortunately, the immune system does not shut down, and as a result, inflammation continues, which in turn destroys the colonic mucosa and causes the symptoms associated with ulcerative colitis.
What are the signs and symptoms of ulcerative colitis?
As the inflammatory response in the inner layer of the intestinal wall becomes more severe and ulcers are formed, it loses its ability to absorb water from food residues. Accordingly, this leads to increasingly loose stools – in other words, diarrhea. Damaged intestinal mucosa can also lead to mucus stools. Also, ulcers in the mucosal layer can cause bleeding, thus producing bloody stools. In fact, continuous blood loss can lead to anemia.
Most patients with ulcerative colitis may experience a sense of bowel urgency and abdominal cramps, which may be predominantly left-sided, as the lower part of the colon is located on the left side.
Diarrhea and abdominal pain may lead to poor appetite and weight loss, and these symptoms can also cause fatigue, which is also a side effect of anemia. Growth and development may be affected in children with ulcerative colitis.
Extra-intestinal manifestations.
In addition to symptoms in the gastrointestinal tract, some patients may experience symptoms in other parts of the body. The following are some of the extra-intestinal signs and symptoms.
Eyes: redness and itching; mouth: ulcers; joints: edema and pain; skin: lumps and other injuries; bone: osteoporosis; kidneys: stone formation; liver: hepatitis and cirrhosis (less common).
These are the main signs and symptoms of ulcerative colitis outside the GI tract. For some patients, these signs and symptoms are first and precede the GI manifestations. For other patients, these signs and symptoms will appear just prior to the sudden onset of the disease.
Patients with an 8-10 year history of ulcerative colitis are at higher risk for colon cancer. You should talk more with your doctor to take steps to prevent cancer and reduce your risk.
Range of symptoms.
About half of patients with ulcerative colitis have relatively mild symptoms. The other half of patients may suffer from severe abdominal cramps, bloody stools, nausea and fever, which are mostly temporary. During the remission period, patients may not have any pain at all. This “disease-free period” may last for months or even years, although symptoms may recur. It is difficult for doctors to conclude whether treatment during this period is effective.
Diagnostic criteria.
How do doctors make the diagnosis of ulcerative colitis? The first step is to obtain a complete family and disease history of the patient, including questions that address the details of the symptoms; the second is a physical examination.
A number of other diseases can also cause diarrhea, abdominal pain, and rectal bleeding, so doctors rely on a variety of different medical tests to rule out other possible diseases, such as infections.
Stool tests can rule out diarrhea caused by bacteria, viruses, parasites, etc., and can likewise confirm the presence of bleeding. Blood tests such as routine blood tests can clarify whether there is anemia, which in turn can indicate whether there is bleeding from the colon or rectum.
In addition, if the blood test has an elevated white blood cell count, it indicates the presence of an infection somewhere in the body.
Observation in the colon.
The next step is to examine the colon with a sigmoidoscope or colon endoscope. With a sigmoidoscope, the doctor inserts a flexible instrument into the rectum and lower colon. This test provides a full view of the colon and allows for a clear visualization of the presence and severity of inflammation. The same principle is used for colon endoscopy, which has the advantage of being able to view the entire extent of the colon.
Using these techniques, your internist will find inflammation, bleeding, or ulcers on the colon, and likewise get a clear picture of the extent of the lesions.
During these examinations, your examining physician may biopsy the mucosal tissue of your colon and send it to a pathologist for further examination. In this way, ulcerative colitis can be distinguished from other diseases – such as Crohn’s disease, colonic diverticula and tumors.
Drug therapy.
As we mentioned before, there is no cure for ulcerative colitis. But there are ways to control it, and they work by suspending the abnormal inflammation in the lining of the colon. Such methods can induce healing of the colonic lesions and also relieve symptoms such as diarrhea, rectal blood in the stool and abdominal pain.
The two basic goals of treatment are to eliminate symptoms and to maintain a symptom-free state. Some medications can achieve both of these goals in varying doses and with different courses of treatment as much as possible.
There is no specific treatment for ulcerative colitis, and treatment options should vary from person to person, as each patient is different.
Some of the medications used in the treatment of ulcerative colitis have been in use for many years, while some are newer in recent years. The most commonly used drugs are currently divided into the following four categories.
1. Aminosalicylates: These drugs are aspirin analogs containing 5-aminosalicylic acid (5-ASA). Examples include salazosulfapyridine, mesalazine, olsalazine, and balsalazide. These drugs can be taken orally or with anal plugs, and they are able to alter the function of the patient’s organism and slow down the inflammatory process. These drugs are effective in mild to moderate ulcerative colitis and, at the same time, prevent the recurrence of the disease.
2. Glucocorticoids: This group of drugs, including prednisone and prednisolone, can influence the body to stimulate and maintain the current state of inflammation. In addition, it can suppress the body’s immune system. Glucocorticoids are commonly used in moderate to severe ulcerative colitis. It can be administered orally, rectally by plugging anus or intravenously and is often used for short-term control treatment of acute attacks. It is not recommended as a long course of treatment or as maintenance therapy because of its high number of side effects. If you become dependent on hormones because of recurrence of symptoms, your doctor will add other types of medications to treat your disease.
3. Immunomodulators: These drugs include azathioprine, 6-mercaptopurine (6-MP), and cyclosporine. These drugs control the continued development of inflammation by suppressing the body’s immune system. Immunomodulators are indicated for patients who are ineffective or partially effective with the use of aminosalicylates and glucocorticoids, usually taken orally. It may also be used to reduce or eliminate a patient’s dependence on glucocorticosteroids. It may be useful in maintaining disease remission when patients do not respond to other medications. Immunomodulators are usually taken for about 3 months to start taking effect.
4. Biologic therapy: This is the newest class of drugs for the treatment of inflammatory bowel disease and includes infliximab. Infliximab is an antibody that binds to tumor necrosis factor-alpha (TNF-alpha), a protein in the immune system that plays an important role in the development of inflammation. This drug has a rapid onset of action, achieves long-term mucosal repair, can aid in steroid withdrawal, and is a maintenance drug in remission. Other biological agents are currently in clinical trials.
Surgical treatment.
Most patients with ulcerative colitis respond well to medications and do not require surgical treatment. Nevertheless, approximately 25-33% of patients may require surgical treatment at some point. Surgery is primarily indicated for a variety of complications. These complications include severe bleeding due to ulcers, intestinal perforation, and toxic megacolon. Toxic megacolon results from severe inflammation and often has significant abdominal distention accompanied by fever and constipation. If recovery does not occur soon after aggressive medical treatment to control inflammation and rehydration, surgery should be performed as soon as possible to avoid rupture of the bowel.
Surgery might be considered to remove the entire colon, called colectomy. Surgery is also a worthwhile option when the effect of medication is not satisfactory or when precancerous lesions occur in the rectum. Because ulcerative colitis is different from Crohn’s disease, once the colon is removed, the ulcer is “cured”.
Depending on the patient’s condition – including the extent of the lesion, age, and general health – different procedures can be performed. The first procedure is a colectomy and proctocolectomy, which can cure ulcerative colitis, but afterwards the patient must be treated with an ileostomy (an opening in the abdomen to drain the debris).
Currently, with the improvement of new techniques, patients can choose another surgical option that removes only the colon, preserving the rectum and avoiding ileostomy. This involves connecting the small bowel to the anal sphincter in vivo; this type of surgery does not require an external ileostomy and preserves rectal function.
Common surgical complications include infection and recurrent chronic inflammation (capsulitis) of the surgical opening (18.8%), decreased female fertility (56-80%), pelvic sepsis (9.5%), and bowel movements of 5.2/24 hours (mean).
When medical medication fails, surgical treatment may be a hope.
Role of nutrition.
You may be wondering if ulcerative colitis was caused or contributed to by any particular food you ate. The answer, of course, is no. Nevertheless, once you have the disease, watching your diet can reduce your symptoms, replace lost nutrients, and promote recovery. For example, when your disease is active, a lighter, softer diet than spicy, high-fiber foods can reduce your discomfort. In addition, eating smaller, more frequent meals may also reduce discomfort.
Maintaining proper nutrition is important for the treatment of ulcerative colitis. Maintaining adequate nutrition is a must in chronic diseases, especially this one. Abdominal pain and fever can cause poor nausea and weight loss. Diarrhea and rectal bleeding can cause the body to lose fluids, nutrients and electrolytes. The balance of these substances plays an important role in maintaining body function.
This does not mean that you must eat certain foods or that you should not eat certain types of foods. With the exception of lactose intolerant patients who should limit their milk intake and those with severe diarrhea who should limit their caffeine intake, most doctors will advise you to take care of nutritional balance and thus prevent nutritional deficiencies. A healthy diet must include a wide variety of foods. Meat, fish, poultry and dairy products (if tolerated) are rich in protein. Breads, cereals, starches, fruits and vegetables contain carbohydrates; butter and vegetable oils contain fats; and a daily multivitamin supplement can help fill food deficiencies.
Probiotics and prebiotics.
Researchers have begun to look for other drugs that have gut-protective effects in people with Crohn’s disease, and probiotics and prebiotics are one of them.
What are these two substances? Probiotics, also known as “beneficial” or “friendly” bacteria, are microorganisms in the intestinal tract that assist in gastrointestinal function.
In the human digestive system, there are about 400 different types of beneficial bacteria that inhibit the growth of harmful bacteria, and it is crucial to achieve a balance between probiotics and pathogenic bacteria. If the number of beneficial bacteria declines, or if this balance is disturbed, then harmful bacteria can overgrow – causing diarrhea and other digestive tract symptoms. If this happens in patients with an already compromised digestive tract, such as those with Crohn’s disease, the symptoms can be particularly severe. Evidence-based medical findings suggest that the use of probiotics (currently available in capsules, powders, liquids, and thin round tablets) may be another treatment option for IBD, especially for maintenance therapy.
Prebiotics are non-digestible food components that provide nutrients to beneficial bacteria, and they also stimulate the growth of probiotics.
Role of stress and emotions.
Some people believe that people with a particular personality type are prone to ulcerative colitis or other inflammatory bowel disease. This is a wrong view. Although the organism and the mind are closely related and emotions can affect the symptoms of ulcerative colitis, by the same token they can affect any other chronic disease. Even though some patients may experience a relapse of Crohn’s disease after a traumatic experience, there is still no evidence that mental stress can cause Crohn’s disease. Mental distress is most likely a symptomatic response to the disease itself, so patients with Crohn’s disease should have the understanding and emotional support of their family and physicians. Although formal psychological treatment is not necessary, some patients can be helped by talking to a specialist with knowledge about inflammatory bowel disease or general chronic disease.
Advance planning.
Even with ulcerative colitis, you can still learn many ways to make life easier for yourself. There are many different ways to deal with this disease. For example, you may be afraid to go out in public when you feel abdominal pain or diarrhea. In fact, this is unnecessary. These situations can be handled if you make arrangements in advance.
It’s a smart idea to locate restrooms in restaurants, malls, theaters and transportation, and to carry extra underwear or toilet paper with you. If you are going to be away for an extended period of time, you should tell your doctor beforehand. Travel planning includes having plenty of medications and their generic names in case you run out or lose them, as well as knowing the name of your local doctor in the area you are traveling to in advance.
Living with Ulcerative Colitis.
Perhaps the most difficult time for people with ulcerative colitis is the moment when they first learn they have the disease. Over time, this idea will slowly change. In the meantime, don’t hide your disease from your family, friends and co-workers. Talk to them about your illness and let them help and support you.
Try to live your life as usual; there is no reason to give up the life you used to enjoy and aspire to. Learning the various ways to deal with the disease and share your knowledge with others, taking your medications as prescribed (even when you feel great), and staying positive are the basics and the best prescriptions.
Although ulcerative colitis is a serious and chronic disease, it is not fatal. There is no doubt that having this disease is a challenge, and you will have to take medication and be hospitalized if necessary. But more importantly, you must remember that even with this disease, you can live a full life. It is also important to remember that adherence to maintenance medications can reduce the symptoms of ulcerative colitis. In remission, most people will feel their symptoms disappear and feel cured.
Looking ahead.
Laboratories around the world have thrown themselves into the study of ulcerative colitis. This is good news for the search for new treatments for the disease, and CCFA-funded research plays a huge role in the field of immunology, microbiology, genetics, and more. Through continued research efforts, we will gain more and more knowledge and eventually find a cure for ulcerative colitis.