Contents
Ulcerative colitis is a disease
that causes inflammation and sores, called ulcers, in the lining of
the rectum and colon. Ulcers form where inflammation has killed the
cells that usually line the colon, then bleed and produce pus.
Inflammation in the colon also causes the colon to empty frequently,
causing diarrhea.
When the inflammation occurs in the
rectum and lower part of the colon it is called ulcerative proctitis.
If the entire colon is affected it is called pancolitis. If only the
left side of the colon is affected it is called limited or distal
colitis.
Ulcerative colitis is an
inflammatory bowel disease (IBD), the general name for diseases that
cause inflammation in the small intestine and colon. It can be
difficult to diagnose because its symptoms are similar to other
intestinal disorders and to another type of IBD called Crohn’s
disease. Crohn’s disease differs because it causes inflammation
deeper within the intestinal wall and can occur in other parts of
the digestive system including the small intestine, mouth,
esophagus, and stomach.
Ulcerative colitis can occur in
people of any age, but it usually starts between the ages of 15 and
30, and less frequently between 50 and 70 years of age. It affects
men and women equally and appears to run in families, with reports
of up to 20 percent of people with ulcerative colitis having a
family member or relative with ulcerative colitis or Crohn’s
disease. A higher incidence of ulcerative colitis is seen in Whites
and people of Jewish descent.
The most common symptoms of
ulcerative colitis are abdominal pain and bloody diarrhea. Patients
also may experience
- anemia
- fatigue
- weight loss
- loss of appetite
- rectal bleeding
- loss of body fluids and
nutrients
- skin lesions
- joint pain
- growth failure (specifically in
children)
About half of the people diagnosed
with ulcerative colitis have mild symptoms. Others suffer frequent
fevers, bloody diarrhea, nausea, and severe abdominal cramps.
Ulcerative colitis may also cause problems such as arthritis,
inflammation of the eye, liver disease, and osteoporosis. It is not
known why these problems occur outside the colon. Scientists think
these complications may be the result of inflammation triggered by
the immune system. Some of these problems go away when the colitis
is treated.
Many theories exist about what
causes ulcerative colitis. People with ulcerative colitis have
abnormalities of the immune system, but doctors do not know whether
these abnormalities are a cause or a result of the disease. The
body’s immune system is believed to react abnormally to the bacteria
in the digestive tract.
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. The stress of
living with ulcerative colitis may also contribute to a worsening of
symptoms.
Many tests are used to diagnose
ulcerative colitis. A physical exam and medical history are usually
the first step.
Blood tests may be done to check
for anemia, which could indicate bleeding in the colon or rectum, or
they may uncover a high white blood cell count, which is a sign of
inflammation somewhere in the body.
A stool sample can also reveal
white blood cells, whose presence indicates ulcerative colitis or
inflammatory disease. In addition, a stool sample allows the doctor
to detect bleeding or infection in the colon or rectum caused by
bacteria, a virus, or parasites.
A colonoscopy or sigmoidoscopy are
the most accurate methods for making a diagnosis of ulcerative
colitis and ruling-out other possible conditions, such as Crohn’s
disease, diverticular disease, or cancer. For both tests, the doctor
inserts an endoscope—a long, flexible, lighted tube connected to a
computer and TV monitor—into the anus to see the inside of the colon
and rectum. The doctor will be able to see any inflammation,
bleeding, or ulcers on the colon wall. During the exam, the doctor
may do a biopsy, which involves taking a sample of tissue from the
lining of the colon to view with a microscope.
Sometimes x rays such as a barium
enema or CT scans are also used to diagnose ulcerative colitis or
its complications.
Treatment for ulcerative colitis
depends on the severity of the disease. Each person experiences
ulcerative colitis differently, so treatment is adjusted for each
individual.
Drug Therapy
The goal of drug therapy is to
induce and maintain remission, and to improve the quality of life
for people with ulcerative colitis. Several types of drugs are
available.
- Aminosalicylates, drugs
that contain 5-aminosalicyclic acid (5-ASA), help control
inflammation. Sulfasalazine is a combination of sulfapyridine and
5-ASA. The sulfapyridine component carries the anti-inflammatory
5-ASA to the intestine. However, sulfapyridine may lead to side
effects such as nausea, vomiting, heartburn, diarrhea, and
headache. Other 5-ASA agents, such as olsalazine, mesalamine, and
balsalazide, have a different carrier, fewer side effects, and may
be used by people who cannot take sulfasalazine. 5-ASAs are given
orally, through an enema, or in a suppository, depending on the
location of the inflammation in the colon. Most people with mild
or moderate ulcerative colitis are treated with this group of
drugs first. This class of drugs is also used in cases of relapse.
- Corticosteroids such as
prednisone, methylprednisone, and hydrocortisone also reduce
inflammation. They may be used by people who have moderate to
severe ulcerative colitis or who do not respond to 5-ASA drugs.
Corticosteroids, also known as steroids, can be given orally,
intravenously, through an enema, or in a suppository, depending on
the location of the inflammation. These drugs can cause side
effects such as weight gain, acne, facial hair, hypertension,
diabetes, mood swings, bone mass loss, and an increased risk of
infection. For this reason, they are not recommended for long-term
use, although they are considered very affective when prescribed
for short-term use.
- Immunomodulators such as
azathioprine and 6-mercapto-purine (6-MP) reduce inflammation by
affecting the immune system. These drugs are used for patients who
have not responded to 5-ASAs or corticosteroids or who are
dependent on corticosteroids. Immunomodulators are administered
orally, however, they are slow-acting and it may take up to 6
months before the full benefit. Patients taking these drugs are
monitored for complications including pancreatitis, hepatitis, a
reduced white blood cell count, and an increased risk of
infection. Cyclosporine A may be used with 6-MP or azathioprine to
treat active, severe ulcerative colitis in people who do not
respond to intravenous corticosteroids.
Other drugs may be given to relax
the patient or to relieve pain, diarrhea, or infection.
Some people have remissions—periods
when the symptoms go away—that last for months or even years.
However, most patients’ symptoms eventually return.
Hospitalization
Occasionally, symptoms are severe
enough that a person must be hospitalized. For example, a person may
have severe bleeding or severe diarrhea that causes dehydration. In
such cases the doctor will try to stop diarrhea and loss of blood,
fluids, and mineral salts. The patient may need a special diet,
feeding through a vein, medications, or sometimes surgery.
Surgery
About 25 to 40 percent of
ulcerative colitis patients must eventually have their colons
removed because of massive bleeding, severe illness, rupture of the
colon, or risk of cancer. 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.
Surgery to remove the colon and
rectum, known as proctocolectomy, is followed by one of the
following:
- Ileostomy, in which the
surgeon creates a small opening in the abdomen, called a stoma,
and attaches the end of the small intestine, called the ileum, to
it. Waste will travel through the small intestine and exit the
body through the stoma. The stoma is about the size of a quarter
and is usually located in the lower right part of the abdomen near
the beltline. A pouch is worn over the opening to collect waste,
and the patient empties the pouch as needed.
- Ileoanal anastomosis, or
pull-through operation, which allows the patient to have normal
bowel movements because it preserves part of the anus. In this
operation, the surgeon removes the colon and the inside of the
rectum, leaving the outer muscles of the rectum. The surgeon then
attaches the ileum to the inside of the rectum and the anus,
creating a pouch. Waste is stored in the pouch and passes through
the anus in the usual manner. Bowel movements may be more frequent
and watery than before the procedure. Inflammation of the pouch (pouchitis)
is a possible complication.
Not every operation is appropriate
for every person. Which surgery to have depends on the severity of
the disease and the patient’s needs, expectations, and lifestyle.
People faced with this decision should get as much information as
possible by talking to their doctors, to nurses who work with colon
surgery patients (enterostomal therapists), and to other colon
surgery patients. Patient advocacy organizations can direct people
to support groups and other information resources.
About 5 percent of people with
ulcerative colitis develop colon cancer. The risk of cancer
increases with the duration of the disease and how much the colon
has been damaged. For example, if only the lower colon and rectum
are involved, the risk of cancer is no higher than normal. However,
if the entire colon is involved, the risk of cancer may be as much
as 32 times the normal rate.
Sometimes precancerous changes
occur in the cells lining the colon. These changes are called "dysplasia."
People who have dysplasia are more likely to develop cancer than
those who do not. Doctors look for signs of dysplasia when doing a
colonoscopy or sigmoidoscopy and when examining tissue removed
during these tests.
According to the 2002 updated
guidelines for colon cancer screening, people who have had IBD
throughout their colon for at least 8 years and those who have had
IBD in only the left colon for 12 to 15 years should have a
colonoscopy with biopsies every 1 to 2 years to check for dysplasia.
Such screening has not been proven to reduce the risk of colon
cancer, but it may help identify cancer early. These guidelines were
produced by an independent expert panel and endorsed by numerous
organizations, including the American Cancer Society, the American
College of Gastroenterology, the American Society of Colon and
Rectal Surgeons, and the Crohn’s & Colitis Foundation of America.
|
