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.ere.

(Also known as: Colitis, Proctitis)

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.​

Ulcerative Colitis
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 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 and possible fever 
  • weight loss 
  • loss of appetite 
  • rectal bleeding 
  • diarrhea with loss of body fluids and nutrients 
  • rectal urgency and pain


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 and inflammatory markers, 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 CT Scan of the abdomen and pelvis or rarely a barium enema x-ray of the colon may also be required. This is another method of visualizing the colon and is often used when pain is present.


What is the treatment for ulcerative colitis?

Treatment for ulcerative colitis depends on the seriousness of the disease. Most people are treated with medication., and in the vast majority of patients, control of symptoms and remission are successful  In severe cases, a patient may need surgery to remove the diseased colon. Surgery is the only complete 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, and was the first medication available in thihs class. 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, therefore this drug is rarely used anymore.  Other 5-ASA agents such as olsalazine (Dipentum), mesalamine (Lialda, Asacol, Delzicol, Apriso, Rowasa), and balsalazide (Colazol), 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. 
  • Newer infusion or injectable mediactions have been developed that are very effective for Crohn's Disease, and these are called anti-TNF inhibitors or "biologics." They are used for the treatment of moderate to severe Crohn's Disease and to retain remission. The biologics can be very effective for the healing of fistulas and other skin lesions associated with Crohn's. The first medication to be approved in this class is Infliximab (brand name, Remicade) for the treatment of moderate to severe Crohn’s disease that does not respond to standard therapies (mesalamine substances, corticosteroids, immunosuppressive agents) and for the treatment of open, draining fistulas. Infliximab approved specifically for Crohn’s disease, is an anti-tumor necrosis factor (TNF) substance. TNF is a protein produced by the immune system that may cause the inflammation associated with Crohn’s disease. Anti-TNF removes TNF from the bloodstream before it reaches the intestines, thereby preventing inflammation. Since then, other biologics are now availble including adalimumab (Humira), certolizumab (Cimzia), golimumab (Simponi), all of which are effective and self injectable at home. The latest infusion medication, vedolizumab (Entyvio) is a humanized monoclonal antibody and has the advantage of causing less reactions than the earlier anti-TNF infusions. In order for someone to begin treatment with these drugs, underlying Tuberculosis needs to be ruled out, and tests for viral hepatitis need to be excluded. The meds may lower your immune system, and therefore there is an increased risk of certain cancers such as lymphoma and skin cancers.


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 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 (J-pouch), 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

New 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.


For more information on this topic, visit:
Crohn's & Colitis Foundation of America Inc.