| Ulcerative colitis is a disease that causes
inflammation and sores, called ulcers, in the top layers of 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 lower section,
called the ileum. Ulcerative colitis may also be called colitis, ileitis,
or proctitis.
The inflammation makes the colon empty frequently, causing diarrhea.
Ulcers form in places where the inflammation has killed colon lining
cells; the ulcers bleed and produce pus and mucus.
Ulcerative colitis is an inflammatory bowel disease (IBD), the general
name for diseases that cause inflammation in the intestines. Ulcerative
colitis can be difficult to diagnose because its symptoms are similar to
other intestinal disorders such as irritable bowel syndrome 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. Crohn's disease usually occurs in the small intestine,
but it can also occur in the mouth, esophagus, stomach, duodenum, large
intestine, appendix, and anus.
Ulcerative colitis occurs most often in people ages 15 to 40, although
children and older people sometimes develop the disease. Ulcerative
colitis affects men and women equally and appears to run in some families.
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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 tell if there is bleeding or
infection in the colon or rectum.
The doctor may do a colonoscopy. For this 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.
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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 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.
Someone with ulcerative colitis may need medical care for some time,
with regular doctor visits to monitor the condition.
Drug Therapy
Most patients with mild or moderate disease are
first treated with 5-ASA agents, a combination of the drugs sulfonamide,
sulfapyridine, and salicylate that helps control inflammation.
Sulfasalazine is the most commonly used of these drugs. Sulfasalazine can
be used for as long as needed and can be given along with other drugs.
Patients who do not do well on sulfasalazine may respond to newer 5-ASA
agents. Possible side effects of 5-ASA preparations include nausea,
vomiting, heartburn, diarrhea, and headache.
People with severe disease and those who do not respond to mesalamine
preparations may be treated with corticosteroids. Prednisone and
hydrocortisone are two corticosteroids used to reduce inflammation. They
can be given orally, intravenously, through an enema, or in a suppository,
depending on the location of the inflammation. Corticosteroids can cause
side effects such as weight gain, acne, facial hair, hypertension, mood
swings, and increased risk of infection, so doctors carefully watch
patients taking these drugs.
Other drugs may be given to relax the patient or to relieve pain,
diarrhea, or infection.
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.
One of several surgeries may be done. The most common surgery is a
proctocolectomy with ileostomy, which is done in two stages. In the
proctocolectomy, the surgeon removes the colon and rectum. In the
ileostomy, 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. This type of ileostomy is called a Brooke ileostomy. 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.
An alternative to the Brooke ileostomy is the continent ileostomy. In
this operation, the surgeon uses the ileum to create a pouch inside the
lower abdomen. Waste empties into this pouch, and the patient drains the
pouch by inserting a tube into it through a small, leakproof opening in
his or her side. The patient must wear an external pouch for only the
first few months after the operation. Possible complications of the
continent ileostomy include malfunction of the leakproof opening, which
requires surgical repair, and inflammation of the pouch (pouchitis), which
is treated with antibiotics.
An ileoanal anastomosis, or pull-through operation, allows the patient
to have normal bowel movements because it preserves part of the rectum.
This procedure is becoming increasingly common for ulcerative colitis. 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 usual.
Pouchitis is a possible complication of this procedure.
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 Resources
for the names of such organizations.)
Most people with ulcerative colitis will never need to have surgery. If
surgery ever 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. Several drugs are being tested to see whether they
might be useful in treating the disease:
- Budesonide. A corticosteroid called budesonide may be nearly
as effective as prednisone in treating mild ulcerative colitis, and it
has fewer side effects.
- Cyclosporine. Cyclosporine, a drug that suppresses the immune
system, may be a promising treatment for people who do not respond to
5-ASA preparations or corticosteroids.
- Nicotine. In an early study, symptoms improved in some
patients who were given nicotine through a patch or an enema. (Using
nicotine as treatment is still experimental--the findings do not mean
that people should go out and buy nicotine patches or start smoking.)
- Heparin. Researchers overseas are examining whether the
anticoagulant heparin can help control colitis by preventing blood
clots.
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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 not higher
than normal. However, if the entire colon is involved, the risk of cancer
may be as great 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 and when examining tissue removed
during the test.)
According to 1997 guidelines on screening for colon cancer, 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 at least 15 years should have a
colonoscopy 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, American College of
Gastroenterology, American Society of Colon and Rectal Surgeons, and the
Crohn's & Colitis Foundation of America Inc., among others.)
Keeping on Top of Your Condition
Keeping in tune with your disease or condition not only makes treatment less intimidating but also increases its chance of success, and has been shown to lower a patients risk of complications. As well, as an informed patient, you are better able to discuss your condition and treatment options with your physician.
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