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Overview
Crohn's Disease
Microscopic Colitis
Ulcerative Colitis

What causes Ulcerative Colitis?
The cause of ulcerative colitis is unknown, though theories exist. People with ulcerative colitis have abnormalities of the immune system, but whether these problems are a cause or a result of the disease is still unclear. The immune system protects people from infection by identifying and destroying bacteria, viruses, and other potentially harmful foreign substances. With ulcerative colitis, the body’s immune system is believed to react abnormally to bacteria in the digestive tract. Ulcerative colitis sometimes runs in families and research studies have shown that certain gene abnormalities are found more often in people with ulcerative colitis.

Ulcerative colitis is not caused by emotional distress, but the stress of living with ulcerative colitis may contribute to a worsening of symptoms. In addition, while sensitivity to certain foods or food products does not cause ulcerative colitis, it may trigger symptoms in some people.

What are the symptoms of UC?
The most common symptoms of ulcerative colitis are abdominal discomfort and blood or pus in diarrhea. Other symptoms include:

  • Anemia
  • Fatigue
  • Fever
  • Nausea
  • Weight loss
  • Loss of appetite
  • Rectal bleeding
  • Loss of body fluids and nutrients
  • Skin lesions
  • Growth failure in children

Most people diagnosed with ulcerative colitis have mild to moderate symptoms. About 10 percent have severe symptoms such as frequent fevers, bloody diarrhea, nausea, and severe abdominal cramps. Ulcerative colitis can also cause problems such as joint pain, eye irritation, kidney stones, liver disease, and osteoporosis. Scientists do not know why these problems occur, but they think these complications may be the result of inflammation triggered by the immune system. Some of these problems go away when ulcerative colitisC is treated.

How is UC diagnosed?
Ulcerative colitis can be difficult to diagnose because its symptoms are similar to those of other intestinal disorders and to Crohn’s disease. Crohn’s disease differs from UC in that Crohn’s disease 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.

A physical exam and medical history are usually the first steps in diagnosing ulcerative colitis, followed by one or more tests and procedures:

  • Blood tests: The blood test can show a high white blood cell (WBC) count, which is a sign of inflammation somewhere in the body. Blood tests can also detect anemia, which could be caused by bleeding in the colon or rectum.
  • Stool test: Stool tests can show WBCs, which indicate ulcerative colitis or another IBD. The sample also allows doctors to detect bleeding or infection in the colon or rectum caused by bacteria, a virus, or parasites.
  • Flexible sigmoidoscopy and colonoscopy: These tests are the most accurate methods for diagnosing ulcerative colitis and ruling out other possible conditions, such as Crohn’s disease, diverticular disease, or cancer.
  • Computerized tomography (CT) scan and barium enema x-ray: A CT scan uses a combination of x-rays and computer technology to create three-dimensional  images. These tests can show physical abnormalities and are sometimes used to diagnose ulcerative colitis.

How is UC treated?
Treatment for ulcerative colitis depends on the severity of the disease and its symptoms. Each person experiences ulcerative colitis differently, so treatment is adjusted for each individual.

Medication Therapy
While no medication cures ulcerative colitis, many can reduce symptoms. The goals of medication therapy are to induce and maintain remission and to improve quality of life. Many people with ulcerative colitis require medication therapy indefinitely, unless they have their colon and rectum surgically removed.

The type of medication prescribed depends on the severity of the ulcerative colitis.

  • Aminosalicylates, medications that contain 5-aminosalicyclic acid (5-ASA), help control inflammation. One medication, sulfasalazine (Azulfidine), is a combination of sulfapyridine and 5-ASA. The sulfapyridine component carries the anti-inflammatory 5-ASA to the intestine. Sulfapyridine may lead to side effects such as nausea, vomiting, heartburn, diarrhea, and headache. Other 5-ASA agents, such as olsalazine (Dipentum), mesalamine (Asacol, Canasa, Lialda, Rowasa), and balsalazide (Colazal), cause fewer side effects, and can be used by people who cannot take sulfasalazine. Depending on which parts of the colon and rectum are affected by ulcerative colitis, 5-ASAs can be given orally; through a rectal suppository, a small plug of medication inserted in the rectum; or through an enema. Unless the ulcerative colitis symptoms are severe, people are usually first treated with aminosalicylates. These medications are also used when symptoms return after a period of remission.
  • Corticosteroids, such as prednisone, methylprednisone, and hydrocortisone, also reduce inflammation. They are used for people with more severe symptoms and people who do not respond to 5-ASAs. Corticosteroids, also known as steroids, can be given orally, intravenously, or through an enema, a rectal foam, or a suppository, depending on which parts of the colon and rectum are affected by ulcerative colitis. Side effects include weight gain, acne, facial hair, hypertension, diabetes, mood swings, bone mass loss, and an increased risk of infection. Because of harsh side effects, steroids are not recommended for long-term use. Steroids are usually prescribed for short-term use and then stopped once inflammation is under control. The other ulcerative colitis medications are used for long-term symptom management.
  • Immunomodulators, such as azathioprine (Imuran, Azasan), 6-mercaptopurine (6-MP) (Purinethol), and cyclosporine (Neoral, Sandimmun, Sandimmune), suppress the immune system. These medications are prescribed for people who do not respond to 5-ASAs. Immunomodulators are given orally, but they are slow-acting and can take 3 to 6 months to take effect. People taking these medications are monitored for complications including nausea, vomiting, fatigue, pancreatitis, hepatitis, a reduced WBC count, and an increased risk of infection. Cyclosporine is only used with severe ulcerative colitis, because one of its frequent side effects is toxicity, which means it can cause harmful effects to the body over time.
  • Infliximab (Remicade) is an anti-tumor necrosis factor (anti-TNF) agent prescribed to treat people who do not respond to the other ulcerative colitis medications or who cannot take 5-ASAs. People taking Infliximab should also take immunomodulators to avoid allergic reactions. Infliximab targets a protein called TNF that causes inflammation in the intestinal tract. The medication is given through intravenous infusion every 6 to 8 weeks at a hospital or outpatient center. Side effects may include toxicity and increased risk of infections, particularly tuberculosis.

Other medications may be prescribed to decrease emotional stress or to relieve pain, reduce diarrhea, or stop infection.

Hospitalization
Sometimes ulcerative colitis symptoms are severe enough that a person must be hospitalized. For example, a person may have severe bleeding or diarrhea that causes dehydration. In such cases, health care providers will use intravenous fluids to treat diarrhea and loss of blood, fluids, and mineral salts. People with severe symptoms may need a special diet, tube feeding, medications, or surgery.

Surgery
About 10 to 40 percent of people with UC eventually need a proctocolectomy—surgery to remove the rectum and part or all of the colon. Surgery is sometimes recommended if medical treatment fails or if the side effects of corticosteroids or other medications threaten a person’s health. Other times surgery is performed because of massive bleeding, severe illness, colon rupture, or cancer risk.

A proctocolectomy is followed by one of the following operations:

  • Ileoanal pouch anastomosis, also called “pouch surgery,” makes it possible for people with ulcerative colitis to have normal bowel movements, because it preserves part of the anus. For this operation, the surgeon preserves the outer muscles of the rectum during the proctocolectomy. The ileum—the lower end of the small intestine—is then pulled through the remaining rectum and joined to 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, called pouchitis, is a possible complication and can lead to symptoms such as increased diarrhea, rectal bleeding, and loss of bowel control. Pouch surgery is the first type of surgery considered for ulcerative colitis because it avoids a long-term ileostomy.
  • Ileostomy is an operation that attaches the ileum to an opening made in the abdomen, called a 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. An ostomy pouch is then attached to the stoma and worn outside the body to collect stool. The pouch needs to be emptied several times a day. An ileostomy performed for ulcerative colitis is usually permanent.

The type of surgery recommended will be based on the severity of the disease and the person’s needs, expectations, and lifestyle. People faced with this decision should get as much information as possible by talking with their doctors; enterostomal therapists, nurses who work with colon surgery patients; other health care professionals; and people who have had colon surgery. Patient advocacy organizations can provide information about support groups and other resources.

Eating, Diet, and Nutrition
Dietary changes may help reduce ulcerative colitis symptoms. A recommended diet will depend on the person’s symptoms, medications, and reactions to food. General dietary tips that may alleviate symptoms include

  • Eating smaller meals more often
  • Avoiding carbonated drinks
  • Eating bland foods
  • Avoiding high-fiber foods such as corn and nuts

For people with ulcerative colitis who do not absorb enough nutrients, vitamin and nutritional supplements may be recommended.

Is colon cancer a concern with Ulcerative Colitis?
People with ulcerative colitis have an increased risk of colon cancer when the entire colon is affected for a long period of time. For example, if only the lower colon and rectum are involved, the risk of cancer is no higher than that of a person without ulcerative colitis. But if the entire colon is involved, the risk of cancer is higher than the normal rate. The risk of colon cancer also rises after having ulcerative colitis for 8 to 10 years and continues to increase over time. Effective maintenance of remission by treatment of ulcerative colitis may reduce the risk of colon cancer. Surgical removal of the colon eliminates the risk of colon cancer.

With ulcerative colitis, precancerous changes—called dysplasia—sometimes occur in the cells lining the colon. People with dysplasia are at increased risk of developing colon cancer. Dr. Jones looks for signs of dysplasia when performing a colonoscopy or flexible sigmoidoscopy and when examining tissue removed during these procedures.

According to the U.S. Preventive Services Task Force guidelines for colon cancer screening, people who have had IBD throughout the colon for at least 8 years and those who have had IBD in only the left side of the 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 and improve prognosis. 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.