Ulcerative Colitis (Inflammatory Bowel Disease)

What is Ulcerative Colitis?

Ulcerative colitis (UC) is a chronic systemic inflammatory disorder. Gastro-intestinal involvement is limited to the large intestine - a "colitis" refers to inflammation of the colon. This is compared with Crohn's Disease which can affect any part of the alimentary tract. Ulcerative colitis usually causes inflammation of the rectum and then extends proximally (further-up) to involve various degrees of the colon. Sometimes it is limited to just a small section of the left-hand side of the colon or it can extend to involve the entire colon (pancolitis). The image below is a comparison of two sections of the colon. The image on the left is indicative of a healthy colon. The colon on the right has developed active, yet still in a mild state, Ulcerative Colitis. Note the inflamed state of the colon on the right.

Ulcerative Colitis (a type of Inflammatory Bowel Disease)

Statistics on Ulcerative Colitis?

For UC, the incidence and prevalence rates range from 3 to 15 per 100,000 and 50 to 80 per 100,000 of the population respectively, slightly higher than the rates for Crohn's disease. The disease affects women more commonly than men and tends to present in the 15-40 year old age group. Ulcerative colitis is most often seen in Western societies and is more common in Caucasian populations.

Risk Factors for Ulcerative Colitis

Having a first degree relative with the disease increases one's risk 3-20 times. Approximately 15% of affected patients have a first degree relative with inflammatory bowel disease.Causes are unknown but genetic and environmental factors are thought to have a role. Diet and infective agents have been postulated as likely contributing factors. Furthermore periods of stress may lead to a relapse.Non-smokers or ex-smokers are at greater risk of UC than smokers as nicotine is thought to have some therapeutic effects on the bowel. However, the reverse is true for Crohn's disease.

Progression of Ulcerative Colitis

Most patients will UC have recurrent episodes requiring some hospital admissions. A small proportion of patients have persistent chronic symptoms without remission and a small proportion have only a single attack. The severity of disease varies widely. If you have only mild disease involving only the rectum, there is a good chance that your disease may resolve spontaneously. More extensive involvement of the colon causes more significant symptoms of diarrhoea and abdominal pain. Pancolitis (inflammation extending up the entire colon) causes additional problems of anaemia (often requiring blood transfusions), weight loss and poor nutrition. Medical treatment is essential in these patients. Having UC for a long duration increases one's risk of developing adenocarcinoma of the colonbowel cancer. It is important that you have appropriate colonoscopy screening after 5 years of UC duration.

Symptoms of Ulcerative Colitis

UC usually presents with rectal bleeding , with or without mucus. Other presenting symptoms may include:

Diarrhoea.
Urgency (sudden urge to pass stools) and tenesmus (the feeling of incomplete defaecation following passage of stools).
Abdominal pain.
Weight loss- in severe cases.
General malaise and lethargy.
Apthous ulcers within the mouth.
Loss of appetite.
Anaemia.
Dehydration.

In most cases these symptoms are of chronic nature and occur at intermittent intervals. The severity of these symptoms can vary. In most cases people have disease confined to the rectum so the former rectal symptoms predominate. Systemic symptoms are less common and are a feature of more extensive disease. Approximately 15% of adult patients have pancolitis where anaemia and weight loss are predominant symptoms. Occasionally UC can present very acutely and you may have severe symptoms requiring hospitalization. The following are acute presentations that you may experience:

Fulminating colitis and toxic megacolon- You will have severe abdominal pain, abdominal distension and will try to lie still to prevent further pain (a sign of inflammation of the peritoneum).
Colonic perforation- If the colon ruptures you will develop sudden pain.
Haemorrhage- Very rarely UC can present with severe bleeding that requires immediate resuscitation.

Note that UC is a type of systemic inflammatory disorder which can cause changes outside the intestinal system. Approximately one third of patients will have at least one of the following features:

Painful or red eyes.
Skin lesions- Approximately 1% of patients will have erythema nodusum (tender red nodules on the shins) or pyoderma gangrenosum (skin ulcers).
Joint pain- Due to inflammation of the joints.
Liver and bile problems- Sclerosing cholangitis occurs in 2.5-7.5% of patients due to damage o the biliary system. Cirrhosis of the liver and jaundice can also occur.

ChildrenUnlike adults, only 25% of children have disease limited to the rectum (proctitis). More extensive disease may be common so the additional systemic features are seen more commonly. Chronic UC in children may be associated with growth retardation.

Clinical Examination of Ulcerative Colitis

There are no specific signs on examination that can tell your doctor whether you have UC. Examination of the abdomen may reveal some distension or tenderness to palpation. Your doctor will also perform a digital rectal examination (insertion of a finger into the anus and rectum) to determine whether any bleeding is present. Your doctor may also examine other systems such as your eyes, joints or skin to detect any of the extra-intestinal manifestations of UC described above.

How is Ulcerative Colitis Diagnosed?

The diagnosis of UC relies on clinical suspicion from a typical history and examination as well as investigations to confirm the diagnosis. Your doctor may perform the following investigations to make a diagnosis of UC:

Full blood count- This may reveal anaemia similar to that seen in other chronic diseases. You may also have an elevated white cell) count if your disease is currently active.
Serum inflammatory markers- ESR and CRP reflect the level of disease activity.
Liver function tests (LFT)- These can help monitor disease activity and determine whether the liver is involved.
Blood cultures if sepsis suspected.
Stool cultures- May be needed if the case of diarrhoea to exclude infective causes.
Sigmoidoscopy and colonoscopy are the main investigations used. These allow visualisation of the colon mucosa and detection of specific inflammatory changes. A biopsy (tissue sample) is essential to confirm the diagnosis and exclude other causes of colitis.
Plain abdominal x-rays are occasionally performed and may be useful excluding Crohn's disease or identifying complications such as toxic megacolon, perforation or obstruction.

Prognosis of Ulcerative Colitis

The prognosis can vary with the disease pattern and the type of course the disease takes. In general if your disease is confined to the rectum only you will have a very good prognosis as only 5-10% of such patients go on to develop further bowel involvement. If you have more severe acute disease with toxic dilatation or perforation, the mortality rate increases to approximately 15-25%. If however, your condition is treated promptly and surgery is undertaken if it does not resolve in 2-3 days, you have a better outcome.In general, because UC is usually a mild disease and because a total colectomy can be curative (unlike in Crohn's Disease) the life expectancy of patients with UC is not unlike that of the general population. There is a higher risk of colorectal cancer for which you require proper surveillance. The risk of colorectal cancer increases with the extent and duration of the disease.

How is Ulcerative Colitis Treated?

Treatment of UC is mainly aimed at relieving your symptoms so you can maintain an adequate quality of life. Most patients can gain symptom relief with regular medications and surgery is only required in severe cases. Recall that UC follows a relapsing and remitting course so daily medication is required to prevent exacerbations. Below is an outline of the treatments used for UC.

Medical treatment:

All patients with UC will usually be treated with an aminosalicylate medication. These medications have been shown to induce remission in mild to moderate active disease and prevent exacerbations. If your disease is distal (proctitis) topical therapy may be preferred such as suppositories or enemas. Extensive disease usually requires systemic medications. If your disease is not adequately managed with aminosalicylates, oral steroids may be added to the treatment regimen. These agents work by reducing inflammation. Immunosuppressive medications (such as cyclosporine or azathioprine) may also be used in very refractory cases or to reduce the amount of steroid required. In acute exacerbations of UC steroid medications are usually used. These can be given topically for proctitis or orally for more extensive disease. Severe exacerbations require hospital admission where intravenous fluids, nutrition and steroids are given. Following the acute attack the intravenous steroids (hydrocortisone) will be changed to an oral medication (prednisolone) and then be slowly tapered. If you fail to respond to medical treatment, surgery may be required. Some patients with severe disease will also require a blood transfusion. Note that it is important to avoid anti-diarrhoeals in severe disease as they can precipitate toxic megacolon which can lead to bowel perforation.

Surgery:

Surgery may be needed in acute severe cases (as described above), in chronic cases unresponsive to medical treatment, and where there is a high risk of developing colorectal cancer. There are various procedures available and you should discuss with your doctor which of these are suitable for you. Some of the procedures such as total colectomy (removal of the entire colon) and panproctocolectomy with ileostomy will require a permanent stoma. This involves attaching the end of the remaining intestine to the abdominal wall so intestinal contents empty into a bag. Other procedures such as proctocolectomy with ileoanal anastamosis and formation of a J pouch reservoir to avoid the need for a stoma. In some emergency cases a colectomy must be performed with a stoma but this can be reversed at a later date whan the bowel has recovered.

Other:

To date there is no evidence that special diets provide any benefits for UC. However it may be useful for you to see a dietician as they can teach you how to maintain adequate nutrition throughout your disease. In some cases you may also be required to take oral iron supplements to manage iron deficiency anaemia. If you have had UC for longer than 8-10 years you are required to have a colonoscopy every 1-2 years to screen for development of colorectal cancer. Patients with UC have a greater risk of colon cancer than the general population. Screening allows it to be detected early whilst surgical therapies are still available.

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