Ulcerative Colitis

What is ulcerative colitis?
Ulcerative colitis is a chronic disease of the colon or large intestine. It is marked by inflammation and ulceration (holes) in the colon’s innermost lining. Tiny, open sores (ulcers) form on the surface of this lining; they bleed and produce pus and mucus. Because the inflammation makes the colon empty frequently, symptoms include diarrhea (sometimes bloody) and, often, abdominal cramping.

The inflammation usually begins in the rectum and lower colon, but it may involve the entire colon. When it affects only the lowest part of the colon — the rectum — it is called ulcerative proctitis. If it affects only the left side of the colon, it is known as limited or distal colitis. Ulcerative colitis involving the entire colon is called pancolitis.

How is ulcerative colitis different from Crohn’s disease?
Ulcerative colitis is different from other inflammatory bowel diseases like Crohn’s disease. Crohn’s can affect any area of the gastrointestinal tract, including the small intestine and colon. Ulcerative colitis, on the other hand, affects only the colon. The inflammation involves the entire rectum and extends continuously up the colon. There are no normal areas of the intestine between the areas of ulceration. In Crohn’s, the inflamed areas are scattered and can affect the entire thickness of the bowel wall.

What are the symptoms of ulcerative colitis?
The first symptom of ulcerative colitis is a progressive loosening of the stool. It’s usually bloody, and the patient also may experience abdominal cramping and severe urgency to have a bowel movement. Diarrhea can begin slowly or very suddenly. Loss of appetite, fatigue and weight loss are very common, and in cases of severe bleeding, anemia may occur. Patients sometimes also have skin lesions, joint pain, eye inflammation and liver disorders. In children, ulcerative colitis may stunt growth.

Some patients may suffer severe abdominal cramps, bloody diarrhea, nausea and fever. About half of patients have milder symptoms. The symptoms come and go with fairly long periods between flare-ups. Periods of remission can last months or years, but the symptoms eventually return.

What is the prevalence of ulcerative colitis?
In the United States, about 1 million people have either ulcerative colitis or Crohn’s disease.

What causes ulcerative colitis?
Ulcerative colitis is an abnormal response by the body’s immune system. The immune system is made up of various cells and proteins. Normally, these protect the body from infection, but in people with ulcerative colitis, the immune system treats food, bacteria and any other materials in the intestines as invaders. It launches an attack, and the body sends white blood cells into the intestinal lining where they produce chronic inflammation. These cells then produce harmful products that lead to ulcerations and bowel injuries.

No one knows what causes this disease. It tends to run in families, but at this time, there isn’t any way to predict which, if any, family members will develop ulcerative colitis. Most cases are diagnosed before the age of 30, although it can occur at any age. More whites than non-whites have the disease, and there is a higher incidence in Jews than in non-Jews.

How is the disease diagnosed?
Physicians make the diagnosis after taking a careful patient history, examining the patient and ordering a series of tests. The first goal of these tests is to make sure that an infection is not causing the diarrhea. Stool specimens are taken, blood tests are analyzed and a barium enema X-ray of the colon may be ordered if the patient is not too sick. The barium shows up white on the X-ray, providing a detailed picture of the colon. Finally, the patient may have a colon evaluation through a sigmoidoscopy or a colonoscopy.

In a sigmoidoscopy, the doctor passes a flexible instrument into the rectum and lower colon. The doctor then can see how much inflammation is in those areas. A total colonoscopy is similar, but it looks at the entire colon to detect bleeding, inflammation or ulcers on the wall. During these procedures, the physician usually takes a sample called a biopsy.

How is ulcerative colitis treated?
There is no cure for ulcerative colitis. Rather, the goal of treatment is to stop the inflammatory response to allow the colon to heal and to relieve the symptoms of diarrhea.

Three major classes of medicines are used to treat the disease:

• Aminosalicylates are aspirin-like drugs that alter the body’s ability to generate and sustain an attack. Without inflammation, the symptoms don’t occur. These drugs usually are given orally or rectally.

• Corticosteroids include prednisone, methylprednisolone and budesonide. These medications are given orally, rectally or through the bloodstream. They are prescribed for patients with moderate to severe disease and affect the body’s ability to launch or sustain an attack. They’re very effective for short-term episodes but are not good for long-term therapy because of their side effects.

• Immunomodulatory medicines (azathioprine, 6-MP and cyclosporine) alter the immune cells’ interaction with the inflammatory process. They usually are given orally to patients when aminosalicylates and corticosteroids haven’t stopped the symptoms. These medicines, though, take as long as three months before they begin to work.
  
  

In 25 to 33 percent of patients with ulcerative colitis, medical therapy isn’t enough. Under these circumstances, surgery is the treatment of choice. This includes the removal of the colon and the rectum. Once the colon and recturm are removed, the ulcerative colitis is cured.

Depending on a number of factors, two different surgical approaches may be used. The first involves the removal of the entire colon and rectum, with the creation of an ileostomy or external stoma (an opening in the abdomen through which wastes are emptied into a pouch that is attached to the skin). A newer and most common option includes removal of the colon and rectum but doesn’t require a permanent ileostomy. An internal pouch is created from the small bowel, and it is attached to the anal sphincter muscle. The patient then doesn’t have to wear an external device/stoma permanently.

Ulcerative colitis is a serious condition, but it’s not fatal. Most people live useful and productive lives, even though they are hospitalized from time to time or need to take medicines. Between flare-ups, many individuals feel well and free of symptoms.

To make an appointment with a Washington University colorectal surgeon, please call (314) 454-7177.

Surgeons who treat ulcerative colitis:

Elisa H. Birnbaum, M.D.

James W. Fleshman, Jr., M.D.

Steven R. Hunt, M.D.

Ira J. Kodner, M.D.

Matthew G. Mutch, M.D.

Bashar Safar MBBS, MRCS