What is Ulcerative Colitis?
Ulcerative colitis (UC) is a form of inflammatory bowel disease that only affects the innermost layer (mucosa) of the large bowel i.e., the colon. As we do not have a way of forcing the immune system to forget something that it has learned to attack, ulcerative colitis is a chronic condition. This means it can be controlled with treatment, but not cured. Some people go for years without having any symptoms, while others have more frequent flares of their disease activity. The goal of medical therapy is to avoid flares, to prevent permanent damage to the lining of the colon.
Cases of ulcerative colitis are classified based on where the disease activity is located and what complications are present.
Location
Disease Complications
Causes
Despite many years of research, the exact cause of ulcerative colitis is not well understood but seems to be a complex interplay of genetic and environmental/lifestyle factors.
Genetics
In ulcerative colitis the immune system attacks the GI tract, so everything that impacts the immune system could contribute to the cause of this disease ...
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Smoking
Smoking damages the immune system and is a known risk factor for ulcerative colitis. People with ulcerative colitis who continue to smoke ...
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Microbiome
An abundance of bacteria living in the last part of the GI tract help provide us with nutrients, and everyone has a unique combination of bacteria ...
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Signs & Symptoms
Ulcerative colitis starts with microscopic inflammation that causes no symptoms. As the immune system damages the lining on a daily basis, the severity of inflammation slowly builds to the point where it can be seen with a camera (endoscopy). As the intestinal lining becomes inflamed and ulcerated, it loses its ability to absorb water from the waste material that passes through the colon. The damaged intestinal lining may begin producing a lot of mucus in the stool. The inflammation at this point can cause progressive loosening of the stool — in other words, diarrhea, and associated urgency to have bowel movements. More severe inflammation can also cause bleeding in the stool, or iron deficiency which can progress to anemia. The most severe form of colitis symptoms is megacolon, when the colon loses the ability to contract and often must be removed surgically.
Depending on the extent of inflammation, ulcerative colitis symptoms vary, but common symptoms include the following:
- Bloody stool and diarrhea: may sometimes be associated with mucus discharge
- Urgency and increased bowel movement frequency: this may include increased defecations at night
- Abdominal pain and discomfort
- Tenesmus: feeling of incomplete evacuation after a bowel movement
- Fever and weight loss
- Extra-intestinal (outside of the abdomen) symptoms: rashes, eye inflammation, blood clots
- Flares (increase in disease activity)
Chronic inflammation causes cellular changes and scar tissue. A colon that is very scarred does not ever return to normal. It can also increase the risk of developing colon cancer. Studies suggest that effective control of inflammation dramatically reduces the risk of colon cancer.
Extra-intestinal Manifestations
Sometimes ulcerative colitis manifests itself outside the intestines with the following conditions:
Diagnosis
There are a number of steps in the diagnosis of ulcerative colitis.
History
Your gastroenterologist will ask you key questions about your symptoms in a confidential manner.
Physical Examination
Your gastroenterologist will conduct a physical examination which looks at the whole body as well as the abdomen.
Laboratory Testing
Blood tests and stool tests are an important step in diagnosing ulcerative colitis and to make sure no complications have developed.
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Imaging and biopsies
To diagnose ulcerative colitis, a camera test (colonoscopy i.e. endoscopy) needs to be performed to assess disease activity and to obtain biopsies (small pieces of tissue) which can confirm the diagnosis. Occasionally other imaging tests need to be done; these may include ultrasound, CT scans, or MRI.
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Medical Treatment
Unfortunately, ulcerative colitis does not yet have a cure. With treatment, the aim is both a lack of symptoms as well as healing of the lining of the bowel. The ultimate goal is to allow people to live full and normal lives.
Everyone will have a different story with ulcerative colitis that will require an individualized approach to treatment. Below is a very brief overview of some of the common medicines and surgeries used to control UC.
Medical treatments for Ulcerative Colitis
5-Aminosalicylic Acid (5-ASA)
Anti-inflammatory medications that work on the lining of the colon.
Immunomodulators (methotrexate, azathioprine)
These alter immune function to prevent flares.
Corticosteroids (prednisone, budesonide)
These suppress the immune system and are most commonly used during flare ups.
Biologics
These are bioengineered proteins that block specific signals that drive intestinal inflammation. They require special testing before use and strict adherence to injections or infusions. The term ‘biologic’ is a generic term -- each biologic is different. Usually administered once every 4-8 weeks.
Some treatments for IBD modulate the immune system to help reduce inflammation in the GI tract. A side effect of modulating the immune system is that it can increase susceptibility to infections. It is recommended to have up-to-date vaccinations before starting certain IBD treatments. The following vaccinations are recommended for everyone with IBD, and your doctor may suggest additional ones that not everyone in the general public will receive.
One time only:
HPV, Shingles, Hepatitis A and B vaccines
Annual:
Influenza injection (no nasal spray)
Every five years:
Pneumonia vaccine, limited to a few doses
Every ten years:
Tetanus vaccine
Surgical Treatment
Medications do not always work to control ulcerative colitis and sometimes surgery is required, particularly when the disease becomes severe. Sometimes inflammation creates ulcers which can result in abscesses (collections of pus) or megacolon. Surgery often results in the removal of some or all of the colon. Finally, people with IBD are at higher risk for colon cancer because of chronic inflammation causing cellular mutations, and surgery is occasionally required to remove either pre-cancerous polyps or cancer.
The following are some of the surgical procedures that people with ulcerative colitis may require:
Ileostomy
An ileostomy connects the end of the small intestine to a surgical opening on the skin of the abdomen connected to a sterile bag that fits in behind clothes. This diverts fecal matter away from the painful and inflamed colon, directly out of the body.
Total colectomy
In severe cases, surgical removal of a portion of the affected GI tract may be necessary. A total colectomy involves removal of the entire colon.
Proctocolectomy
Proctocolectomy is the surgical removal of the colon and the rectum.
Ileal Pouch-Anal Anastomosis (IPAA)
IPAA involves the removal of affected sections of bowel as well as the creation of a pouch between the end of the small intestine (ileum) and the rectum. This allows patients to function without a permanent stoma although completely normal bowel function is rarely achieved.
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