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Understanding Ulcers
Ulcerative Colitis
National Digestive Diseases Information Clearinghouse, NIH Publication No.
03–1597
Ulcerative colitis is a disease that causes inflammation and sores, called
ulcers, in the lining of the large intestine. The inflammation usually occurs in
the rectum and lower part of the colon, but it may affect the entire colon.
Ulcerative colitis rarely affects the small intestine except for the end
section, called the terminal ileum. Ulcerative colitis may also be called
colitis or proctitis.
The inflammation makes the colon empty frequently, causing diarrhea. Ulcers form
in places where the inflammation has killed the cells lining the colon; the
ulcers bleed and produce pus.
Ulcerative colitis is an inflammatory bowel disease (IBD), the general name for
diseases that cause inflammation in the small intestine and colon. Ulcerative
colitis 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 from ulcerative colitis because it causes inflammation deeper
within the intestinal wall. Also, Crohn's disease usually occurs in the small
intestine, although it can also occur in the mouth, esophagus, stomach,
duodenum, large intestine, appendix, and anus.
Ulcerative colitis may occur in people of any age, but most often it starts
between ages 15 and 30, or less frequently between ages 50 and 70. Children and
adolescents sometimes develop the disease. Ulcerative colitis affects men and
women equally and appears to run in some families.
What causes ulcerative colitis?
Theories about what causes ulcerative colitis abound, but none have been proven.
The most popular theory is that the body's immune system reacts to a virus or a
bacterium by causing ongoing inflammation in the intestinal wall.
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. 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.
What are the symptoms of ulcerative colitis?
The most common symptoms of ulcerative colitis are abdominal pain and bloody
diarrhea. Patients also may experience
fatigue
weight loss
loss of appetite
rectal bleeding
loss of body fluids and nutrients
About half of patients have mild symptoms. Others suffer frequent fever, bloody
diarrhea, nausea, and severe abdominal cramps. Ulcerative colitis may also cause
problems such as arthritis, inflammation of the eye, liver disease (hepatitis,
cirrhosis, and primary sclerosing cholangitis), osteoporosis, skin rashes, and
anemia. No one knows for sure why problems occur outside the colon. Scientists
think these complications may occur when the immune system triggers inflammation
in other parts of the body. Some of these problems go away when the colitis is
treated.
How is ulcerative colitis diagnosed?
A thorough physical exam and a series of tests may be required to diagnose
ulcerative colitis.
Blood tests may be done to check for anemia, which could indicate bleeding in
the colon or rectum. Blood tests may also uncover a high white blood cell count,
which is a sign of inflammation somewhere in the body. By testing a stool
sample, the doctor can detect bleeding or infection in the colon or rectum.
The doctor may do a colonoscopy or sigmoidoscopy. For either test, 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. A barium enema x
ray of the colon may also be required. This procedure involves filling the colon
with barium, a chalky white solution. The barium shows up white on x ray film,
allowing the doctor a clear view of the colon, including any ulcers or other
abnormalities that might be there.
What is the treatment for ulcerative colitis?
Treatment for ulcerative colitis depends on the seriousness of the disease. Most
people are treated with medication. In severe cases, a patient may need surgery
to remove the diseased colon. Surgery is the only cure for ulcerative colitis.
Some people whose symptoms are triggered by certain foods are able to control
the symptoms by avoiding foods that upset their intestines, like highly seasoned
foods, raw fruits and vegetables, or milk sugar (lactose). Each person may
experience ulcerative colitis differently, so treatment is adjusted for each
individual. Emotional and psychological support is important.
Some people have remissions—periods when the symptoms go away—that last for
months or even years. However, most patients' symptoms eventually return. This
changing pattern of the disease means one cannot always tell when a treatment
has helped.
Some people with ulcerative colitis may need medical care for some time, with
regular doctor visits to monitor the condition.
Drug Therapy
The goal of 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
and is used to induce and maintain remission. The sulfapyridine component
carries the anti-inflammatory 5-ASA to the intestine. However, sulfapyridine may
lead to side effects such as include nausea, vomiting, heartburn, diarrhea, and
headache. Other 5-ASA agents such as olsalazine, mesalamine, and balsalazide,
have a different carrier, offer 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.
Corticosteroids such as prednisone 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, mood swings, and an increased risk
of infection. For this reason, they are not recommended for long-term use.
Immunomodulators such as azathioprine and 6-mercapto-purine (6-MP) reduce
inflammation by affecting the immune system. They are used for patients who have
not responded to 5-ASAs or corticosteroids or who are dependent on
corticosteroids. However, immunomodulators are slow-acting and may take up to 6
months before the full benefit is seen. Patients taking these drugs are
monitored for complications including pancreatitis and 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.
Hospitalization
Occasionally, symptoms are severe enough that the 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 percent 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 diseased part of 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 passed 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. (See For More Information for the names of such organizations.)
Most people with ulcerative colitis will never need to have surgery. If surgery
does become necessary, however, some people find comfort in knowing that after
the surgery, the colitis is cured and most people go on to live normal, active
lives.
Research
Researchers are always looking for new treatments for ulcerative colitis.
Therapies that are being tested for usefulness in treating the disease include
Biologic agents. These include monoclonal antibodies, interferons, and other
molecules made by living organisms. Researchers modify these drugs to act
specifically but with decreased side effects, and are studying their effects in
people with ulcerative colitis.
Budesonide. This corticosteroid may be nearly as effective as prednisone in
treating mild ulcerative colitis, and it has fewer side effects.
Heparin. Researchers are examining whether the anticoagulant heparin can help
control colitis.
Nicotine. In an early study, symptoms improved in some patients who were given
nicotine through a patch or an enema. (This use of nicotine is still
experimental—the findings do not mean that people should go out and buy nicotine
patches or start smoking.)
Omega-3 fatty acids. These compounds, naturally found in fish oils, may benefit
people with ulcerative colitis by interfering with the inflammatory process.
Is colon cancer a concern?
About 5 percent of people with ulcerative colitis develop colon cancer. The risk
of cancer increases with the duration and the extent of involvement of the
colon. 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
the test.
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
should it develop. 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 Inc., among
others.
Hope Through Research
NIDDK, through the Division of Digestive Diseases and Nutrition, conducts and
supports research into many kinds of digestive disorders, including ulcerative
colitis. Researchers are studying how and why the immune system is activated,
how it damages the colon, and the processes involved in healing. Through this
increased understanding, new and more specific therapies can be developed.
For More Information
Crohn's & Colitis Foundation of America Inc.
386 Park Avenue South, 17th floor
New York, NY 10016–8804
Phone: 1–800–932–2423 or 212–685–3440
Fax: 212–779–4098
Email: info@ccfa.org
Internet: www.ccfa.org
Pediatric Crohn's & Colitis Association Inc.
P.O. Box 188
Newton, MA 02468
Phone: 617–489–5854
Internet: pcca.hypermart.net
Reach Out for Youth With Ileitis and Colitis Inc.
84 Northgate Circle
Melville, NY 11747
Phone: 631–293–3102
Fax: 631–293–3103
Email: reachoutforyouth@reachoutforyouth.org
Internet: www.reachoutforyouth.org
United Ostomy Association Inc.
19772 MacArthur Boulevard, Suite 200
Irvine, CA 92612–2405
Phone: 1–800–826–0826 or 949–660–8624
Fax: 949–660–9262
Email: info@uoa.org
Internet: www.uoa.org
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