Ulcerative Colitis




Ulcerative colitis as the name suggests is a disorder of the bowel and is a type of inflammatory bowel disorder( IBD) . This shares a presentation similar to another common IBD known as Crohn's disease.


Typically presenting in the 2nd to 4th decade it is a chronic problem associated with inflammation of the lining of the colon or large intestine. Frequent diarrhea, bloody stools and abdominal cramping, flare ups occur intermittently lasting months. Rarely the inflammation may lead to bowel perforation and or toxic megacolon and present with fever, malaise, weight loss and loss of apetitie. Crohn's disease though presents  similarly is associated with greater thickness of inflammation and often affects the entire wall of the bowel through and through leading to sinus tracts known as fistulas and changes to the wall structure leading to narrowing or strictures. The inflammation in Crohns disease are spotty and occur as skip lesions unlike the more continuous inflammation seen in Ulcerative Colitis. 


Additional symptoms may present that are not related to the bowel. These include arthritis, eye inflammatory disorders including uveitis, sclera, iris, conjunctiva inflammation (scleritis, iritis, conjunctivitis). Rarely skin manifestations with erythema nodosum, small elevated red tender spots occur. Liver disorders and coagulopathy with clotting abnormalities leading to clots, and rarely lung airway inflammatory disorders can affect an individual with IBD.


Genetic predisposition plays a role as upto one fourth of those with a first-degree relative may develop Ulcerative Colitis. Smoking is also a strong risk factor. Sensitivity to milk proteins, refined sugars, and dietary habits including low fiber intake and high animal fat intake may also contribute to the development of UC. Dietary Omega-3 seems to be  protective. Physical activity is helpful as obesity is an independent risk factor.  Rarely bowel infections may also be associated with inflammatory bowel disorder. NSAIDs or nonsteroidal anti-inflammatory drugs such as ibuprofen, naproxen, etc and  oral contraceptives may also play a role in IBD. Appendicectomy has been associated with a lower risk of ulcerative colitis suggesting that conditions with persisting inflammation may be important.


Testing would include blood tests for inflammation including erythrocyte sedimentation rate, C reactive protein, which are usually elevated. Fecal  calprotectin or lactoferrin are markers of intestinal inflammation and may be elevated too. Other lab tests to exclude other diagnostic possibilities  include stool studies for ova and parasites, stool cultures, C. difficile toxin. Testing for syphilis, gonorrhea may be important. P-ANCA may be elevated in cases of ulcerative colitis.


Imaging studies including :


CT scan of the abdomen with contrast: may demonstrate thickening of the bowel wall.


Abdominal ultrasounds: may also help in picking up thickening of the wall of the bowel


Barium contrast enema : may show evidence of ulcers, narrowing of the lumen, polyps and diffuse reticular pattern of involvement.   


Finally endoscopy and biopsy is necessary to confirm a diagnosis of colitis and exclude other possibilities. Flexible sigmoidoscopy is usually performed in sicker patients who are unlikely to tolerate more invasive scope procedures due to the risk of perforation.




Other diagnostic possibilities include Crohn's disease, infections of the intestines, radiation related changes, postsurgical effects, post bone marrow transplant-related graft-versus-host disease, and medication-related diarrheal illnesses, and diverticular involvement ( in which sparing of the orifice of the diverticula in contrast to UC which affects the orifice too).  


Though remission episodes last for months an occasional patient's may have difficulty achieving remission. In these cases and long-term chronic cases other rare complications may occur including bowel cancer, strictures and fistulas.


Treatment consists of  initial medical management followed in many cases with curative surgery .


Medical management: Consists of steroids IV initially or oral glucocorticoids, 5-ASA or 5 aminosalicylates, sulfasalazine (Azulfidine 500-1000mg q6hr), balsalazide, mesalamine [oral (Pentasa 1000mg 4 times daily or Apriso 1.5g once daily) or (rectal  Rowasa)], budesonide (uceris rectal or oral), hydrocortisone rectal, and occasional antibiotic therapy for infections(bacteremia, sepsis, C. difficile and toxic megacolon). Medical therapy also includes anti-TNF antibodies or infliximab (Remicade- IV treatment at 0,2,6 weeks) a monoclonal antibody against TNF or tumor necrosis factor. This usually helps in steroid unresponsive Crohn's disease. Cyclosporin immunosuppressants has also been used for inducing remission in patient's who are refractory to steroids. Tacrolimus has been used in children. Other immunosuppressants include Immuran or azathioprine (Azasan), mercaptopurine.


Once the initial flare is controlled, an oral corticosteroid can be continued. Mesalamine,  5-ASA may be used in addition. Those with severe colitis may require long-term treatment with immunomodulating therapy including infliximab. Tylenol usually helps pain. Hot packs, may be helpful too. Opioids are best avoided.


Surgical management includes colectomy or removal of the colon followed by an iliorectal anastomosis. After surgery steroids may not need to be continued. Your Gastroenterologist physician will help decide which treatment option suits you.


Tips for Ulcerative Colitis and IBD.


Stop smoking


Test for sensitivity to milk proteins


Avoid refined sugars


Take a high fiber diet


Avoid  high animal fat or oil intake may


Supplement diet with  Omega-3 rich foods or omega 3 fatty acid supplements


Adopt a lifestyle with healthy physical activity. Lose weight.


Monitor for any bowel infections


Avoid NSAIDs or nonsteroidal anti-inflammatory drugs such as ibuprofen, naproxen, etc and  oral contraceptives