ulcerative colitis

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Vol. 1 No. 1 (2024)

Date Log

Submitted
May 23, 2024
Accepted
June 25, 2024
Published
June 7, 2024

Ulcerative Colitis: Causes, Symptoms and Treatment Options

https://doi.org/10.69512/ajphi.v1i01.40
Gauri Adhikari, MD
Nepalese Army Institute of Health Sciences-College of Medicine, Nepal
Pradeep Khatiwada, MD
B.P. Koirala Institute of Health Sciences, Dharan, Nepal

Corresponding Author(s) : Gauri Adhikari, MD

gauryadhikary@gmail.com

The American Journal of Patient Health Info, Vol. 1 No. 1 (2024)

Abstract


  1. Ulcerative colitis (UC) is an inflammatory bowel disease that chronically inflames the colon and rectum, causing symptoms like abdominal pain, diarrhea, and rectal bleeding. 

  2. It's an autoimmune disorder where the immune system attacks the digestive tract, possibly due to genetic and environmental factors. 

  3.  A family history of inflammatory bowel disease (IBD), including ulcerative colitis, significantly increases the risk. People with close relatives with IBD are at a higher risk of developing the condition.

  4. A colonoscopy or sigmoidoscopy with an intestinal biopsy is required to confirm the diagnosis of UC.

  5. Complications of UC include severe bleeding, colon perforation, increased cancer risk, osteoporosis, and systemic effects, necessitating regular monitoring and comprehensive management for better long-term outcomes.

Keywords

Ulcerative Colitis Toxic Megacolon Colonoscopy IBD
Adhikari, MD, G., & Khatiwada, MD, P. (2024). Ulcerative Colitis: Causes, Symptoms and Treatment Options. The American Journal of Patient Health Info, 1(1). https://doi.org/10.69512/ajphi.v1i01.40
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References
  1. Lynch WD, Hsu R. Ulcerative Colitis. PubMed. Treasure Island (FL): StatPearls Publishing; 2021.
  2. Cleveland Clinic. Ulcerative Colitis [Internet]. Cleveland Clinic. 2020. Available from: https://my.clevelandclinic.org/health/diseases/10351-ulcerative-colitis
  3. Caliendo G, D’Elia G, Makker J, Passariello L, Albanese L, Molinari AM, et al. Biological, genetic and epigenetic markers in ulcerative colitis. Adv Med Sci 2023;68(2):386–95.
  4. Matsuoka K, Kobayashi T, Ueno F, Matsui T, Hirai F, Inoue N, et al. Evidence-based clinical practice guidelines for inflammatory bowel disease. J Gastroenterol 2018;53(3):305–53.
  5. Kałużna A, Olczyk P, Komosińska-Vassev K. The Role of Innate and Adaptive Immune Cells in the Pathogenesis and Development of the Inflammatory Response in Ulcerative Colitis. J Clin Med 2022;11(2):400.
  6. Ulcerative Colitis [Internet]. www.hopkinsmedicine.org. Available from: https://www.hopkinsmedicine.org/health/conditions-and-diseases/ulcerative-colitis
  7. DeRoche TC, Xiao SY, Liu X. Histological evaluation in ulcerative colitis. Gastroenterology Report. 2014 Aug 1;2(3):178–92.
  8. Sands BE, Kaplan GG. The Role of TNFα in Ulcerative Colitis. The Journal of Clinical Pharmacology. 2007 Aug;47(8):930–41.
  9. NHS. Treatment - Ulcerative colitis [Internet]. NHS. 2019. Available from: https://www.nhs.uk/conditions/ulcerative-colitis/treatment/
  10. Ulcerative Colitis Treatment Options [Internet]. Crohn’s & Colitis Foundation. Available from: https://www.crohnscolitisfoundation.org/patientsandcaregivers/what-is-ulcerative-colitis/treatment-options
  11. Manser CN, Borovicka J, Seibold F, Vavricka SR, Lakatos PL, Fried M, et al. Risk factors for complications in patients with ulcerative colitis. United European Gastroenterology Journal. 2016 Apr 1 [cited 2021 Oct 26];4(2):281–7.
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Gauri Adhikaria, Pradeep Khatiwadab

a Nepalese Army Institute of Health Sciences-College of Medicine, Kathmandu, Nepal

b B.P. Koirala Institute of Health Sciences, Dharan, Nepal

Background

Ulcerative colitis is a chronic inflammatory bowel disease (IBD) characterized by ongoing inflammation and ulcers (sores) in the digestive tract. Ulcerative colitis is a common condition with a prevalence of more than 5 million cases worldwide.1

This condition falls under the umbrella of IBD alongside Crohn's disease, but it has unique features and primarily affects the colon and rectum. The inflammation in Ulcerative colitis usually starts from the rectum and spreads to the entire colon.

It has different names depending on the location it affects most.2

  • Ulcerative Colitis: Inflammation affecting the lower part of the colon and rectum.
  • Limited Colitis: Inflammation only in a limited area of the colon.
  • Pancolitis: Inflammation in the entire colon.

Risk Factors for Ulcerative Colitis

There are various risk factors associated with ulcerative colitis. It can affect people of any age, gender, or race, but the risk of getting it increases with the following factors:

Figure 1.

  • Genetic Predisposition: A family history of IBD, including ulcerative colitis, significantly increases the risk. People with close relatives with IBD are at a higher risk of developing the condition.3
  • Age: Although ulcerative colitis can develop at any age, it is most commonly diagnosed in individuals between the ages of 15 and 30 and those over 60.3
  • Ethnicity: Certain ethnic groups, such as Ashkenazi Jews, are at a higher risk of developing ulcerative colitis than others.
  • Prior Gastrointestinal Infections: Some individuals who have experienced severe gastrointestinal infections may have a slightly increased risk of developing ulcerative colitis. This is an area of ongoing research.
  • Non-steroidal anti-inflammatory Drugs (NSAIDs): Long-term use of NSAIDs for other conditions can also increase some individuals’ risk of developing ulcerative colitis.4

Causes of Ulcerative Colitis

The exact cause of ulcerative colitis is unknown, and researchers believe that an overactive or dysregulated immune system is thought to play a significant role in ulcerative colitis. In a healthy immune response, the immune system defends the body against harmful invaders, such as bacteria and viruses. However, in people with ulcerative colitis, the immune system may mistakenly attack the cells lining the colon, leading to chronic inflammation.5

Symptoms of Ulcerative Colitis

The symptoms of ulcerative colitis can vary widely depending on the severity of inflammation and the location. Some may experience mild, intermittent symptoms, while others may have more severe and persistent issues. Additionally, periods of remission, during which symptoms improve or disappear, can occur between flare-ups. Some of the common symptoms are:

Figure 2.

  • Diarrhea: Persistent and often urgent bowel movements with loose, watery stools are a hallmark symptom of ulcerative colitis. You can have a strong and sudden urge to have a bowel movement, often accompanied by an inability to control in some cases.2
  • Abdominal Pain: Crampy abdominal pain, usually in the lower left side of the abdomen, is a frequent symptom.
  • Rectal Bleeding: If the location of inflammation is the rectum, blood in the stool or toilet paper is a common sign. The amount of bleeding can vary depending on the degree of inflammation. With ongoing bleeding for a long time, you can also have anemia, leading to fatigue and weakness.2
  • Tenesmus: It is a feeling of incomplete bowel evacuation, where you still feel the urge to pass stool.
  • Weight Loss: Unintended weight loss is another common symptom and may occur due to decreased appetite, malabsorption, and inflammation-induced metabolic changes.
  • Joint Pain: Joint pain or swelling, known as arthralgia or arthritis, can be associated with ulcerative colitis in some cases and might be the most problematic symptom of all.2
  • Skin and Eye Problems: Inflammation from ulcerative colitis can affect the skin (rash) and eyes, causing uveitis or episcleritis in some individuals.2

Diagnosis of Ulcerative Colitis

Your doctor may order medical tests, including blood, stool, and imaging studies, to diagnose ulcerative colitis.

Figure 3.

  • Blood Tests: Blood tests can help assess the patient's overall health and detect any signs of inflammation or anemia that can be associated with ulcerative colitis. They might reveal signs of an infection or other gastrointestinal conditions that could have triggered the attack.
  • Stool Sample Analysis: A stool sample may be collected and analyzed to rule out infections and check for blood in the stool.
  • Imaging Studies: Imaging tests such as X-rays, computed tomography (CT) scans, or magnetic resonance imaging (MRI) may be performed to visualize the gastrointestinal tract and assess the extent of inflammation.
  • Colonoscopy or Sigmoidoscopy: These are crucial procedures for diagnosing ulcerative colitis. An endoscope is a tube with a camera at one end called an endoscope is inserted through the mouth, nose, or anus to examine the different parts of the digestive tract. A Colonoscopy is done to visualize the entire colon and rectum, whereas a sigmoidoscopy is used to view the lower part of the colon and rectum.6
  • Biopsy: Small tissue samples are often taken during colonoscopy to confirm the diagnosis by examining the tissue under a microscope. It helps to identify the area of changes in the colon lining, such as inflammation, ulcers, and abnormal cell patterns characteristic of ulcerative colitis.7

Treatment of Ulcerative Colitis

The management of ulcerative colitis is highly individualized. Treatment plans are tailored to each patient's specific symptoms, disease severity, and response to therapy. It may involve a combination of approaches, and adjustments may be made over time to achieve and maintain remission.

Figure 4.

1. Medications

Medications for ulcerative colitis can reduce colonic inflammation and promote tissue healing. It can reduce the frequency of symptom flare-ups and manage and suppress symptoms, maintaining remission.

  • Biologics: Biologic medications, such as anti-tumor necrosis factor (TNF) drugs like infliximab or adalimumab, target specific immune system proteins associated with ulcerative colitis and can be effective for moderate to severe cases.8
  • Janus Kinase (JAK) Inhibitors: Medications like tofacitinib may be used in certain cases to reduce inflammation by targeting specific enzymes in the immune system.9
  • Topical Medications: Suppositories or enemas containing corticosteroids or aminosalicylates may be prescribed for localized inflammation in the rectum.
  • Anti-Inflammatory Medications: These are often the first line of treatment and may include aminosalicylates (e.g., sulfasalazine, mesalamine) to reduce inflammation in the colon.
  • Corticosteroids: In cases of moderate to severe symptoms or during flare-ups, corticosteroids like prednisone may be prescribed to reduce inflammation quickly. Due to side effects, these are typically not used for long-term treatment.
  • Immunomodulators: Drugs like azathioprine and 6-mercaptopurine can suppress the immune system and help maintain remission.

2. Dietary and Nutritional Management

Maintaining a healthy diet is essential for ulcerative colitis patients. Common symptoms like diarrhea can also decrease the body's capacity to absorb protein, fat, carbohydrates, water, vitamins, and minerals. In cases of malnutrition or nutrient deficiencies, nutritional supplementation may be necessary. While no specific diet universally treats ulcerative colitis, some individuals find relief by identifying and avoiding trigger foods.

3. Surgery

Surgery is an option if medications are not helping or you have life-threatening complications such as bleeding or to prevent/treat growths that are likely cancers. Studies have shown about 30% of people need surgery during their lifetime. The surgical procedure includes

  • Proctocolectomy and Ileoanal Pouch: It is a common procedure for ulcerative colitis. However, it can require more than one surgery. In this procedure, the entire colon and rectum are removed. The surgeon then creates an internal J-pouch using a small intestine (ileum) section. The pouch is connected to the anal canal allowing for a normal bowel movement. This procedure is typically performed in two stages. In the first stage, the pouch is created, and a temporary ileostomy is constructed. In the second stage, the ileostomy is closed, allowing bowel movements to pass through the pouch and out through the anus. 10
  • ILeostomy: A temporary or permanent ileostomy may be necessary if a J-pouch or other procedures are unsuitable after proctocolectomy. An ileostomy diverts waste material directly from the small intestine to an ostomy pouch outside the body.
  • Subtotal Colectomy: This surgery involves the removal of a significant portion of the colon, leaving part of the colon intact. It may be considered when the disease is limited to a specific portion of the colon or when a complete colectomy is unnecessary. 10

Complications of Ulcerative Colitis

Ulcerative colitis is a chronic disorder and can lead to various complications, some of which can be life-threatening. Some of the complications associated with ulcerative colitis are:

Figure 5.

  • Colon Cancer: Individuals with long-standing, extensive ulcerative colitis have an increased risk of developing colorectal cancer. Regular colonoscopies with biopsies are recommended for early detection and prevention.
  • Toxic Megacolon: Inflammation in the colon can cause it to become severely dilated and lead to a life-threatening condition known as toxic megacolon. Symptoms include abdominal pain, distension, fever, and rapid heart rate.11
  • Perforation: Severe inflammation can weaken the walls of the colon, increasing the risk of perforation. This can lead to a serious abdominal infection called peritonitis.
  • Strictures: It is the narrowing of the colon. Chronic inflammation can cause scar tissue formation and strictures in the colon, leading to bowel obstructions.
  • Fistulas: Inflammation may create abnormal connections called fistulas between the colon and nearby organs, such as the bladder, skin, or other parts of the gastrointestinal tract.
  • Osteoporosis: Malabsorption of nutrients and long-term use of corticosteroids can lead to reduced bone density and an increased risk of fractures.

When To See The Doctor?

You need to call your doctor if you experience:

  • Blood in your stool.
  • Ongoing diarrhea that doesn't respond to medications.
  • Severe stomach discomfort or cramping.
  • High-grade fever.

Questions To Ask Your Doctor

  1. What are the potential side effects of the medications used to treat ulcerative colitis?
  2. How often will I need to see you for follow-up appointments, and what should I expect during these appointments?
  3. What are the potential long-term complications of ulcerative colitis?
  4. How will ulcerative colitis affect my ability to work, travel, and exercise?
  5. What can I do at home to ease my symptoms?
  6. What should I do if my symptoms worsen or if I experience new symptoms?

References

  1. Lynch WD, Hsu R. Ulcerative Colitis. PubMed. Treasure Island (FL): StatPearls Publishing; 2021. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459282/
  2. Cleveland Clinic. Ulcerative Colitis [Internet]. Cleveland Clinic. 2020. Available from: https://my.clevelandclinic.org/health/diseases/10351-ulcerative-colitis
  3. Caliendo G, D’Elia G, Makker J, Passariello L, Albanese L, Molinari AM, et al. Biological, genetic and epigenetic markers in ulcerative colitis. Adv Med Sci 2023;68(2):386–95. Available from: https://pubmed.ncbi.nlm.nih.gov/37813048/
  4. Matsuoka K, Kobayashi T, Ueno F, Matsui T, Hirai F, Inoue N, et al. Evidence-based clinical practice guidelines for inflammatory bowel disease. J Gastroenterol 2018;53(3):305–53. Available from: https://pubmed.ncbi.nlm.nih.gov/29429045/
  5. Kałużna A, Olczyk P, Komosińska-Vassev K. The Role of Innate and Adaptive Immune Cells in the Pathogenesis and Development of the Inflammatory Response in Ulcerative Colitis. J Clin Med 2022;11(2):400. Available from: https://pubmed.ncbi.nlm.nih.gov/35054093/
  6. Ulcerative Colitis [Internet]. www.hopkinsmedicine.org. Available from: https://www.hopkinsmedicine.org/health/conditions-and-diseases/ulcerative-colitis
  7. DeRoche TC, Xiao SY, Liu X. Histological evaluation in ulcerative colitis. Gastroenterology Report. 2014 Aug 1;2(3):178–92. Available from:https://pubmed.ncbi.nlm.nih.gov/24942757/
  8. Sands BE, Kaplan GG. The Role of TNFα in Ulcerative Colitis. The Journal of Clinical Pharmacology. 2007 Aug;47(8):930–41. Available from: https://pubmed.ncbi.nlm.nih.gov/17567930/
  9. NHS. Treatment - Ulcerative colitis [Internet]. NHS. 2019. Available from: https://www.nhs.uk/conditions/ulcerative-colitis/treatment/
  10. Ulcerative Colitis Treatment Options [Internet]. Crohn’s & Colitis Foundation. Available from: https://www.crohnscolitisfoundation.org/patientsandcaregivers/what-is-ulcerative-colitis/treatment-options
  11. Manser CN, Borovicka J, Seibold F, Vavricka SR, Lakatos PL, Fried M, et al. Risk factors for complications in patients with ulcerative colitis. United European Gastroenterology Journal. 2016 Apr 1 [cited 2021 Oct 26];4(2):281–7. Available from: https://pubmed.ncbi.nlm.nih.gov/27087958/

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