Ulcerative colitis is a form of inflammatory bowel disease (IBD). It causes swelling, ulcerations, and loss of function of the large intestine.
The primary problem in IBD is inflammation, as the name suggests. Inflammation is a process that often occurs in order to fight off foreign invaders in the body, including viruses, bacteria, and fungi. In response to such organisms, the body's immune system begins to produce a variety of cells and chemicals intended to stop the invasion. These immune cells and chemicals, however, also have direct effects on the body's tissues, resulting in heat, redness, swelling, and loss of function. No one knows what starts the cycle of inflammation in IBD, but the result is a swollen, boggy intestine.
In ulcerative colitis, the inflammation affects the lining of the rectum and large intestine. It is thought that the inflammation begins in the last segment of the large intestine, which empties into the rectum (sigmoid colon). This inflammation may spread through the entire large intestine, but only rarely affects the very last section of the small intestine (ileum). The rest of the small intestine remains normal.
Ulcerative colitis differs from Crohn's disease, which is a form of IBD that affects both the small and large intestines. The inflammation of ulcerative colitis occurs only in the lining of the intestine (unlike Crohn's disease which affects all of the layers of the intestinal wall). As the inflammation continues, the tissue of the intestine begins to slough off, leaving pits (ulcerations) which often become infected.
Like Crohn's disease, ulcerative colitis occurs in all age groups, with the most common age of diagnosis being 15-35 years of age. Men and women are affected equally. Whites are more frequently affected than other racial groups, and people of Jewish origin have 3-6 times greater likelihood of suffering from any IBD. IBD is familial; an IBD patient has a 20% chance of having other relatives who are fellow sufferers.
Causes and symptoms
No specific cause of ulcerative colitis has been identified. Although no organism (virus, bacteria, or fungi) has been found to set off the cycle of inflammation that occurs in ulcerative colitis, some researchers continue to suspect that some such organism is responsible for initiating the cycle. Other researchers are concentrating on identifying some change in the cells of the colon that would make the body's immune system accidentally begin treating those cells as foreign invaders. Other evidence for such a disorder of the immune system includes the high number of other immune disorders that tend to accompany ulcerative colitis.
The first symptoms of ulcerative colitis are abdominal cramping and pain
, a sensation of urgent need to have a bowel movement (defecate), and blood and pus in the stools. Some patients experience diarrhea, fever, and weight loss. If the diarrhea
continues, signs of severe fluid loss (dehydration
) begin to appear, including low blood pressure, fast heart rate, and dizziness
Severe complications of ulcerative colitis include perforation of the intestine (in which the wall of the intestine develops a hole), toxic dilation of the colon (in which the colon become quite large in diameter), and the development of colon cancer
Intestinal perforation occurs when long-standing inflammation and ulceration of the intestine weakens the wall to such a degree that a hole occurs. This is a life-threatening complication, because the contents of the intestine (which under normal conditions contains a large number of bacteria) spill into the abdomen. The presence of bacteria in the abdomen can result in a massive infection called peritonitis
Toxic dilation of the colon is thought to occur because the intestinal inflammation interferes with the normal function of the muscles of the intestine. This allows the intestine to become lax, and its diameter begins to increase. The enlarged diameter thins the walls further, increasing the risk of perforation and peritonitis. When the diameter of the intestine is quite large, and infection is present, the condition is referred to as "toxic megacolon."
Patients with ulcerative colitis have a significant risk of developing colon cancer
. This risk seems to begin around 10 years after diagnosis of ulcerative colitis. The risk becomes statistically greater every year:
- At 10 years, the risk of cancer is about 0.5-1%.
- At 15 years, the risk of cancer is about 12%.
- At 20 years, the risk of cancer is about 23%.
- At 24 years, the risk of cancer is about 42%.
The overall risk of developing cancer seems to be greatest for those patients with the largest extent of intestine involved in ulcerative colitis.
Patients with ulcerative colitis also have a high chance of experiencing other disorders, including inflammation of the joints (arthritis), inflammation of the vertebrae (spondylitis), ulcers in the mouth and on the skin, the development of painful, red bumps on the skin, inflammation of several areas of the eye, and various disorders of the liver and gallbladder.
Diagnosis is first suspected based on the symptoms that a patient is experiencing. Examination of the stool will usually reveal the presence of blood and pus (white blood cells). Blood tests may show an increase in the number of white blood cells, which is an indication of inflammation occurring somewhere in the body. The blood test may also reveal anemia, particularly when a great deal of blood has been lost in the stool.
The most important method of diagnosis is endoscopy, during which a doctor passes a flexible tube with a tiny, fiberoptic camera device through the rectum and into the colon. The doctor can then examine the lining of the intestine for signs of inflammation and ulceration that might indicate ulcerative colitis. A tiny sample (biopsy) of the intestine will be removed through the endoscope, which will be examined under a microscope for evidence of ulcerative colitis. Because of the increased risk of cancer in patients with ulcerative colitis, endoscopic exam will need to be repeated frequently. Biopsies should be taken regularly, to closely monitor the intestine for the development of cancer or precancerous changes.
X-ray examination is helpful to determine the amount of intestine affected by the disease. However, x-ray examinations requiring the use of barium should be delayed until treatment has begun. Barium is a chalky solution that the patient drinks or is administered through the rectum and into the intestine (enema). The presence of barium in the intestine allows more detail to be seen on x-ray pictures. However, because of the risk of intestinal perforation in ulcerative colitis, most doctors begin treatment before stressing the wall of the intestine with the barium solution.
Treatment for ulcerative colitis addresses the underlying inflammation, as well as the problems occurring due to continued diarrhea and blood loss.
Inflammation is treated with a drug called sulfasalazine. Sulfasalazine is made up of two parts. One part is related to the sulfa antibiotics
; the other part is a form of the anti-inflammatory chemical salicylic acid (related to aspirin
). Sulfasalazine is not well-absorbed from the intestine, so it stays mostly within the intestine, where it is broken down into its components. It is believed to be primarily the salicylic acid component that is active in treating ulcerative colitis, by fighting inflammation. For patients who do not respond to sulfasalazine, steroid medications (such as prednisone) are the next choice.
Depending on the degree of blood loss, a patient with ulcerative colitis may require blood transfusions and fluid replacement through a needle in the vein (intravenous or IV). Medications that can slow diarrhea must be used with great care, because they may actually cause the development of toxic megacolon.
A patient with toxic megacolon requires close monitoring and care in the hospital. He or she will usually be given steroid medications through an IV, and may be put on antibiotics. If these measures do not improve the situation, the patient will have to undergo surgery to remove the colon. This is done because the risk of death
after perforation of toxic megacolon is greater than 50%.
Similarly, a patient with proven cancer of the colon, or even a patient who shows certain signs thought to indicate a precancerous condition, will need his or her colon removed. Removal of the colon is called a colectomy. When a colectomy is performed, a piece of the small intestine (ileum) is pulled through an opening in the abdomen. This bit of intestine is fashioned surgically to allow a special bag to be placed over it, in order to catch the body's waste (feces) which no longer can be passed through the large intestine and out of the anus. This opening, which will remain for the duration of the patient's life, is called an ileostomy.
Remission refers to a disease becoming inactive for a period of time. The rate of remission of ulcerative colitis (after a first attack) is nearly 90%. Those individuals whose colitis is confined primarily to the left side of the large intestine have the best prognosis. Those individuals with extensive colitis, involving most or all of the large intestine, have a much poorer prognosis. Recent studies show that about 10% of these patients will have died by 10 years after diagnosis. About 20-25% of all ulcerative colitis patients will require colectomy. Unlike the case for patients with Crohn's disease, however, such radical surgery results in a cure of the disease.
Crohn's and Colitis Foundation of America, Inc. 386 Park Avenue South, 17th Floor, New York, NY 10016-8804. (800) 932-2423.
— A type of medical examination in which an instrument called an endoscope is passed into an area of the body (the bladder or intestine, for example). The endoscope usually has a fiberoptic camera, which allows a greatly magnified image to be projected onto a video screen, to be viewed by the operator. Many endoscopes also allow the operator to retrieve a small sample (biopsy) of the area being examined, in order to more closely view the tissue under a microscope.
— The system of the body that is responsible for producing various cells and chemicals that fight off infection by viruses, bacteria, fungi, and other foreign invaders. In autoimmune disease, these cells and chemicals are turned against the body itself.
— The result of the body's attempts to fight off and wall off an area that is infected. Inflammation results in the classic signs of redness, heat, swelling, and loss of function.
inflammation of the colon. There are many types of colitis, each with different etiologies; the differential diagnosis involves the clinical history, stool examinations, sigmoidoscopy, and radiologic studies such as a lower gastrointestinal series. One of the most common types is idiopathic ulcerative colitis,
which is characterized by extensive ulcerations along the mucosa and submucosa of the bowel. Other types often can be traced to such etiologic factors as bacteria and viruses, drugs such as antibiotics, and radiation from x-rays or radioactive materials. Strong emotions can cause hypermotility of the gut and thereby produce symptoms typical of colitis. True colitis should be distinguished from irritable bowel syndrome
(formerly referred to by other names such as mucous colitis, irritable colon,
and spastic colon
); in the latter condition there is no actual inflammation of the gastrointestinal mucosa. Almost all forms of colitis cause lower abdominal pain, bleeding from the bowel, and diarrhea. The patient may have as many as 20 bowel movements a day, resulting in serious depletion of body fluids and electrolytes. Treatment is aimed at eliminating or mitigating the underlying cause of the inflammatory process, resting and soothing the inflamed bowel, and restoring the nutritional status and fluid and electrolyte balance to normal.
colitis associated with antimicrobial therapy, most commonly with lincomycin
, but also with other broad-spectrum antibiotics, such as ampicillin
. It can range from mild nonspecific colitis and diarrhea to severe fulminant pseudomembranous colitis
with profuse watery diarrhea, abdominal cramps, and fever. The inflammation may be caused by a toxin produced by Clostridium difficile,
a microorganism that is normally present in the resident bowel flora of infants, but is rarely found in adults. Presumably, the disruption of the normal flora allows the growth of C. difficile.
collagenous colitis a type of colitis of unknown etiology characterized by deposits of collagenous material beneath the epithelium of the colon, with crampy abdominal pain and watery diarrhea.
diversion colitis inflammation in a nonfunctioning colonic pouch created by corrective surgery; it resolves following restoration of intestinal continuity.
ischemic colitis acute vascular insufficiency of the colon, usually involving the portion supplied by the inferior mesenteric artery; symptoms include pain at the left iliac fossa, bloody diarrhea, low-grade fever, abdominal distention, and abdominal tenderness. The classic radiologic sign is thumbprinting, due to localized elevation of the mucosa by submucosal hemorrhage or edema. Ulceration may follow.
a severe acute inflammation of the bowel mucosa, with the formation of pseudomembranous plaques; it is usually associated with antimicrobial therapy (antibiotic-associated colitis
). The common symptoms are watery diarrhea, abdominal cramps, and fever. The pathologic lesions are yellow-green pseudomembranous plaques of mucinous inflammatory exudate distributed in patches over the colonic mucosa and sometimes also in the small intestine. Called also pseudomembranous enterocolitis
radiation colitis colitis resulting from radiation therapy to the abdominal region; it is manifested clinically by tenesmus, pain, rectal bleeding, diarrhea, and telangiectases. Malabsorption, ulceration, and partial or complete obstruction may follow.
ulcerative [ul´sĕ-ra″tiv, ul´ser-ah-tiv]
pertaining to or characterized by ulceration.
a recurrent acute and chronic disorder characterized by extensive inflammatory ulceration in the colon, chiefly of the mucosa and submucosa. The etiology is unknown; hence, the term idiopathic
is used in reference to ulcerative colitis. The disorder is not always limited to pathologic changes in the colon, but may become systemic, involving the joints and causing migratory arthritis, sacroileitis, and ankylosing spondylitis. Other organs that can become involved are the liver, skin, and eyes. Hypercoagulability may also be seen.
Ulcerative colitis shares many of the same characteristics with regional ileitis or crohn's disease
; the two are often included in the broader diagnostic entity called inflammatory bowel disease
. There are some who believe that both disorders are immunologic responses to the same as yet unknown etiologic agent.
Genetic predisposition to inflammatory bowel disease may exist; there is a higher incidence of ulcerative colitis and Crohn's disease among close relatives. Ulcerative colitis is slightly more prevalent in females than in males and most often appears between the ages of 15 and 20 years with a smaller peak at 55 to 60 years of age. Crohn's disease follows a similar pattern of incidence.
Clinical Manifestations and Complications
. The patient with ulcerative colitis suffers from attacks of bloody, mucoid diarrhea that are usually precipitated by physical or emotional stress. These acute attacks can last for days, weeks, or even months and are followed by periods of remission that can extend from a few weeks to several decades. Some patients experience relatively few attacks throughout their lifetime, while others have frequent, prolonged, and potentially serious attacks that predispose the colon to malignant changes. Both acute and chronic diarrhea can upset the fluid and electrolyte balance, interfere with normal nutrition, and produce fever, abdominal cramps, and weight loss.
A sudden and severe attack of the disease can lead to cessation of bowel function and toxic megacolon
or dilatation of the colon. This can occur spontaneously, or it may be preceded by barium enema, hyperkalemia, or anticholinergic narcotics, or there may be bacterial overgrowth with production of exotoxin. Other complications include severe blood loss and anemia, systemic toxicity, and metabolic disturbances. A serious sequela of long-term chronic and continuous ulcerative colitis is carcinoma of the colon, which occurs in approximately 5% of people with ulcerative colitis. The risk of it is lower for persons who have infrequent relapses than for those who are symptomatic for years. Guidelines on screening for colon cancer have been developed by an expert panel and endorsed by numerous organizations concerned with the care of patients with GI diseases. They advise colonoscopy
every one to two years for people who have had inflammatory bowel disease throughout the colon for at least 8 years or who have had it in the left colon for at least 15 years.
. During acute attacks, the patient will most likely present problems related to fluid volume deficit, alteration in nutrition, loss of electrolytes, potential for skin breakdown in the anal region, disturbance of sleep and rest, and discomfort from abdominal cramps. Long-term problems are likely to be related to anxiety, alterations in self-concept, social isolation, and fear of malignancy.
The plan of care should include observation of the number and character of stools, periodic auscultation of bowel sounds, measurement of intake and output, daily weight, checking for signs of bleeding and anemia, and monitoring of blood gases, electrolytes, and pH for evidence of acid-base imbalance or abnormal electrolyte values. It also is important to be alert for signs of inflammatory changes in the joints or lesions on the skin.
When diagnostic procedures such as sigmoidoscopy, barium enema, and stool analyses are necessary, patients should have a satisfactory explanation of the purpose of these tests and what is expected of them before, during, and after each procedure.
Long-term goals of care should help the patient comply with the prescribed medical regimen, which usually consists of antidiarrheic agents, anticholinergic drugs to relieve abdominal cramps, mild sedatives, and a diet of low-residue, bland foods that have high caloric and protein content. Antibiotics are sometimes needed to control infections of the bowel.
Surgical intervention may be the only alternative when more conservative treatments fail. The surgery usually involves creation of a permanent ileostomy
, which brings on a new set of problems.
There is no cure for ulcerative colitis, and it is a debilitating disorder that can create many physiologic, psychological, and social problems for the patient. The frequent bouts of severe diarrhea and discomfort can be embarrassing and depressing. Emotional support, empathetic listening, and cooperative problem solving are essential components of patient care. Further information may be obtained by writing The Crohn's and Colitis Foundation of America Inc., 386 Park Avenue South, 17th floor, New York, NY 10016-8804, calling them at 1-800-932-2423 or 1-212-685-3440, or consulting their web site at http://www.ccfa.org.