Ulcerative Colitis

What is ulcerative colitis?

Ulcerative colitis, a type of inflammatory bowel disease, is an inflammation of the lining of the large bowel (colon). The cause of ulcerative colitis remains unknown.

What are the types of ulcerative colitis?

Ulcerative colitis can be classified into different types based on the area of the large intestine affected. The main types of ulcerative colitis include:

1. Ulcerative proctitis: Inflammation is limited to the rectum, the last part of the colon.
2. Left-sided colitis: Inflammation extends from the rectum up to the descending colon, the left side of the abdomen.
3. Pancolitis (extensive colitis): Affects the entire colon.
4. Acute severe ulcerative colitis: A severe form of ulcerative colitis that affects the entire colon, leading to severe pain, continuous bleeding, dehydration and risk of complications such as toxic megacolon. It requires urgent medical treatment.

What are the symptoms of ulcerative colitis?

The symptoms of ulcerative colitis vary depending on the severity of inflammation and the area of the colon affected. Common symptoms include:

• Diarrhoea: Often persistent and may contain blood or mucus
• Abdominal pain and cramping: Typically felt in the lower abdomen
• Urgency to pass stool: A frequent and sudden need to use the toilet
• Rectal bleeding: Blood mixed in the stool
• Fatigue: Due to chronic inflammation, blood loss, or poor appetite
• Weight loss: As a result of chronic inflammation and poor appetite
• Fever: May occur in more severe cases
• Anaemia: Caused by chronic blood loss leading to low iron levels

When should you see a doctor?

Medical advice is recommended if you struggle with ongoing digestive issues, especially if symptoms interfere with daily life or do not improve with dietary changes. Unexplained weight loss, persistent fatigue or blood in the stool should not be ignored, as they may indicate worsening inflammation.

What are the potential complications of ulcerative colitis?

Ulcerative colitis may lead to a number of serious complications that affect both the digestive system and overall health. These include:

• Severe bleeding from the colon
• Perforation of the colon (a hole in the bowel wall)
• Toxic megacolon, a rare but life-threatening swelling/enlarging of the colon
• Increased risk of colon cancer, especially with long-standing disease where inflammation is poorly controlled in the colon
• Dehydration and electrolyte imbalance due to frequent diarrhoea
• Osteoporosis resulting from long-term corticosteroid use or malabsorption
• Inflammation in other parts of the body, such as the eyes, skin and joints
• Delayed growth and development in children and adolescents
• Primary sclerosing cholangitis, a condition affecting the bile ducts
• Blood clots, including deep vein thrombosis and pulmonary embolism

How can ulcerative colitis be prevented?

There is no guaranteed way to prevent ulcerative colitis, but certain lifestyle choices may help reduce the risk of flare-ups and manage symptoms. These include:

• Eating a balanced diet: Consuming a variety of nutrient-rich foods to support gut health
• Avoiding trigger foods: Identifying and limiting foods that worsen symptoms, such as spicy foods, dairy or high-fat meals
• Managing stress: Practising relaxation techniques like meditation, yoga or deep breathing to help reduce flare-ups
• Maintaining a healthy weight: Keeping a stable weight through a balanced diet and regular exercise
• Avoiding smoking: While smoking has complex effects on ulcerative colitis, quitting is beneficial for overall health
• Taking prescribed medication: Following medical advice and continuing maintenance treatment to prevent relapse. Paracetamol can be used for mild pain. Non-steroidal anti-inflammatory drugs (NSAID), such as ibuprofen and naproxen, should be avoided as they can worsen symptoms.

What causes ulcerative colitis?

The exact cause of ulcerative colitis is unknown, but it is believed to result from an abnormal immune response. In people with ulcerative colitis, the immune system mistakenly attacks the lining of the colon, leading to chronic inflammation.

What are the risk factors for ulcerative colitis?

Certain factors may increase the likelihood of developing ulcerative colitis, including:

• Family history: Having a parent or sibling with ulcerative colitis increases the risk
• Age: The condition is most commonly diagnosed between the ages of 15 and 30, though it can develop later in life

How is ulcerative colitis diagnosed?

Ulcerative colitis is diagnosed through a combination of medical history, physical examination and diagnostic tests. The main methods include:

• Medical history and physical examination: A doctor will assess symptoms, family history and any previous digestive issues, followed by an abdominal examination.
• Blood tests: Used to check for signs of inflammation, anaemia or infection.
• Stool tests: Help rule out infections and detect markers of inflammation in the digestive tract.
• Colonoscopy or sigmoidoscopy: A flexible tube with a camera is used to examine the colon and rectum, allowing for the detection of inflammation, ulcers and bleeding. A biopsy may be taken for further analysis.
• Imaging tests: X-rays, CT scans or MRI scans may be used to assess the extent of inflammation and rule out complications such as perforation or abscesses.

How is ulcerative colitis treated?

Medication

The main aim of treatment is to reduce symptoms and improve a patient’s overall quality of life.

The type of medication will depend on the severity and type of the disease.

• Aminosalicylates / 5-ASA: Taken orally, it is used to reduce inflammation and can also be used as a suppository or an enema
• Corticosteroids: To reduce inflammation effectively
• Immunosuppressant, such as Azathioprine: To reduce the activity of the immune system
• Biologic agents (given as infusion or injection) and Janus kinase (JAK) inhibitors (oral): To target the immune system and reduce inflammation

Surgery

Surgery is needed for life-threatening complications. This includes massive bleeding, perforation or severe infection. It may also be necessary for those who have the chronic form of the disease, where medication fails to work or when the side-effects of medication are intolerable. In addition, patients who have long-standing ulcerative colitis and have a high risk of developing cancer may be offered surgery.

What are the types of surgery for ulcerative colitis?

Proctocolectomy

Historically, the standard operation for ulcerative colitis has been removal of the entire colon, rectum and anus. This operation is called a proctocolectomy. It cures the disease and removes all risk of developing cancer in the colon or rectum. However, this operation requires a permanent ileostomy.

Some patients may be treated by removal of the colon, while leaving behind the rectum and anus. The small bowel can then be re-connected to the rectum and patients can pass motion normally. However, there is an increased risk of ongoing disease in the rectum, increased stool frequency and cancer in the retained rectum.

leoanal pouch procedure

The currently preferred operation by colorectal surgeons is an ileoanal pouch procedure. This is the newest alternative. This procedure removes all of the colon and rectum but preserves the anal canal.

The rectum is replaced with small bowel, which is refashioned to form a small pouch. A temporary ileostomy is created while the pouch is allowed to heal, but this is closed a few months later. The pouch acts as a reservoir to help decrease the stool frequency. This maintains a normal route of defecation, but most patients experience five to ten bowel movements per day.

Patients can develop inflammation of the pouch, which requires antibiotic treatment. In a small percentage of patients, the pouch fails to function properly and may have to be removed. If the pouch is removed, a permanent ileostomy will be necessary.

It is important to recognise that none of these alternatives makes a patient with ulcerative colitis normal. Each alternative has perceivable advantages and disadvantages, which must be carefully understood by the patient prior to selecting the operation that will allow the patient to pursue the highest quality of life.

References

 Centers for Disease Control and Prevention. (n.d.). Ulcerative colitis: The basics. https://www.cdc.gov/inflammatory-bowel-disease/about/ulcerative-colitis-uc-basics.html

Crohn’s & Colitis Foundation. (n.d.). Ulcerative colitis treatment options. https://www.crohnscolitisfoundation.org/patientsandcaregivers/what-is-ulcerative-colitis/treatment-options

Yale Medicine. (n.d.). Ulcerative colitis. https://www.yalemedicine.org/conditions/ulcerative-colitis

Ungaro, R., Mehandru, S., Allen, P. B., Peyrin-Biroulet, L., & Colombel, J. F. (2020). Ulcerative colitis. Nature Reviews Disease Primers, 6, Article 74. https://doi.org/10.1038/s41572-020-0205-x