Ulcerative Colitis
What is Ulcerative Colitis?
Ulcerative colitis is a chronic inflammation of the large intestine (colon).
In patients with ulcerative colitis, ulcers and inflammation of the inner lining of the colon lead to symptoms of abdominal pain, diarrhea, and rectal bleeding.
Ulcerative colitis is closely related to another condition of inflammation of the intestines called Crohn’s disease.
What Causes Ulcerative Colitis?
- Ulcerative colitis likely involves abnormal activation of the immune system in the intestines.
- Genetic susceptibility
- Prolonged stress or Associated psychiatric Disorder.
What are the Symptoms of Ulcerative Colitis?
Common symptoms of ulcerative colitis include rectal bleeding and diarrhea,
The different types of ulcerative colitis are classified according to the location and the extent of inflammation:
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- Ulcerative proctitis refers to inflammation that is limited to the rectum. In many patients with ulcerative proctitis, mild intermittent rectal bleeding may be the only symptom. Other patients with more severe rectal inflammation may, in addition, experience rectal pain, urgency (sudden feeling of having to defecate and a need to rush to the bathroom for fear of soiling), and tenesmus (ineffective, painful urge to move one’s bowels).
- Proctosigmoiditis involves inflammation of the rectum and the sigmoid colon (a short segment of the colon contiguous to the rectum). Symptoms of proctosigmoiditis, like that of proctitis, include rectal bleeding, urgency, and tenesmus. Some patients with proctosigmoiditis also develop bloody diarrhea and cramps.
- Left-sided colitis involves inflammation that starts at the rectum and extends up the left colon (sigmoid colon and the descending colon). Symptoms of left-sided colitis include bloody diarrhea, abdominal cramps, weight loss, and left-sided abdominal pain.
- Pancolitis or universal colitis refers to inflammation affecting the entire colon (right colon, left colon, transverse colon and the rectum). Symptoms of pancolitis include bloody diarrhea, abdominal pain and cramps, weight loss, fatigue, fever, and night sweats. Some patients with pancolitis have low-grade inflammation and mild symptoms that respond readily to medications. Generally, however, patients with pancolitis suffer more severe disease and are more difficult to treat than those with more limited forms of ulcerative colitis.
- Fulminant colitis is a rare but severe form of pancolitis. Patients with fulminant colitis are extremely ill with dehydration, severe abdominal pain, protracted diarrhea with bleeding, and even shock. They are at risk of developing toxic megacolon (marked dilatation of the colon due to severe inflammation) and colon rupture (perforation). Patients with fulminant colitis and toxic megacolon are treated in the hospital with potent intravenous medications. Unless they respond to treatment promptly, surgical removal of the diseased colon is necessary to prevent colon rupture.
How is the Diagnosis of Ulcerative Colitis Made?
- The diagnosis of ulcerative colitis is suggested by the symptoms of abdominal pain, rectal bleeding, and diarrhea.
- Stool specimens are collected for analysis to exclude infection and parasites, since these conditions can cause colitis that mimics ulcerative colitis.
- Blood tests may show anemia and an elevated white blood cell count or sedimentation rate. An elevated white blood cell count and sed rate both reflect ongoing inflammation in the colon.
- Other blood tests may also be checked including monitoring the kidney function, liver function tests, iron studies, and C-reactive protein (another sign of inflammation).
- There is some evidence that a stool test for a protein called calprotectin could be useful in identifying patients who would benefit from colonoscopy. Calprotectin seems to be a sensitive marker of intestinal inflammation, so elevated levels suggest inflammatory bowel disease in the right setting. This test alone, however, cannot distinguish between different diseases causing the inflammation so should be used with caution.
- Confirmation of ulcerative colitis requires a test to visualize the large intestine. Flexible tubes inserted through the rectum (sigmoidoscopes and colonoscopes) permit direct visualization of the inside of the colon to establish the diagnosis and to measure the extent of the colitis. Small tissue samples (biopsies) can be obtained during the procedure to determine the severity of the colitis.
- A barium enema X-ray may also indicate the diagnosis of ulcerative colitis. During a barium enema, a chalky substance is administered into the rectum and injected into the colon. Barium is radiopaque and can outline the colon on x-ray pictures. A barium enema is less accurate and useful than direct visualization techniques in the diagnosis of ulcerative colitis.
What are the Complications of Ulcerative Colitis?
- Blood transfusions, pancolitis, and toxic megacolon
- Cancers
- Other complications of ulcerative colitis
- Complications of ulcerative colitis can involve other parts of the body.
- Ten percent of the patients can develop inflammation of the joints (arthritis).
- Some patients have low back pain due to arthritis of the sacroiliac joints.
- Ankylosing spondylitis (AS) is a type of arthritis that affects the vertebral joints of affected individuals. There seems to be an increased incidence of ankylosing spondylitis among patients with inflammatory bowel disease.
- Rarely, patients may develop painful, red, skin nodules (erythema nodosum). Others can have painful, red eyes (uveitis, episcleritis). Because these particular complications can risk permanent vision impairment, eye pain or redness are symptoms that require a physician’s evaluation.
- Diseases of the liver and bile ducts may also be associated with ulcerative colitis. For example, in patients with a rare condition called sclerosing cholangitis, repeated infections and inflammation in the bile ducts can lead to recurrent fever, yellowing of skin (jaundice), cirrhosis, and the need for a liver transplant.
- Finally, patients with ulcerative colitis also might have an increased tendency to form blood clots, especially in the setting of active disease.
What are the Treatments for Ulcerative Colitis?
Both medications and surgery have been used to treat ulcerative colitis. However, surgery is reserved for those with severe inflammation and life-threatening complications. As far as medicine is concern there is no such in allopathic side, that can cure ulcerative colitis. Patients with ulcerative colitis will typically experience periods of relapse (worsening of inflammation) followed by periods of remission (resolution of inflammation) lasting months to years. During relapses, symptoms of abdominal pain, diarrhea, and rectal bleeding worsen. During remissions, these symptoms subside. Remissions usually occur because of treatment with medications or surgery, but occasionally they occur spontaneously, that is, without any treatment.
What are ulcerative colitis medications in allopathic side ?
Since ulcerative colitis cannot be cured by medication, the goals of treatment with medication are to
- induce remissions,
- maintain remissions,
- minimize side effects of treatment,
- improve the quality of life, and
- minimize risk of cancer. Treatment of ulcerative colitis with medications is similar, though not always identical, to treatment of Crohn’s disease.
Medications treating ulcerative colitis include
- anti-inflammatory agents such as 5-ASA compounds, systemic corticosteroids, topical corticosteroids, and
- immunomodulators.
Anti-inflammatory medications that decrease intestinal inflammation are analogous to arthritis medications that decrease joint inflammation (arthritis). The anti-inflammatory medications that are used in the treatment of ulcerative colitis are:
- Topical 5-ASA compounds such as sulfasalazine (Azulfidine), olsalazine (Dipentum), and mesalamine (Pentasa, Asacol, Lialda, Apriso Rowasa enema) that need direct contact with the inflamed tissue in order to be effective.
- Systemic anti-inflammatory medications such as corticosteroids that decrease inflammation throughout the body without direct contact with the inflamed tissue. Systemic corticosteroids have predictable side effects with long term use.
Immunomodulators are medications that suppress the body’s immune system either by reducing the cells that are responsible for immunity, or by interfering with proteins that are important in promoting inflammation. Immunomodulators increasingly are becoming important treatments for patients with severe ulcerative colitis who do not respond adequately to anti-inflammatory agents.
Systemic Corticosteroids (including side effects)
Corticosteroids (Prednisone, prednisolone, hydrocortisone, etc.) have been used for many years in the treatment of patients with moderate to severe Crohn’s disease and ulcerative colitis or who fail to respond to optimal doses of 5-ASA compounds. Unlike the 5-ASA compounds, corticosteroids do not require direct contact with the inflamed intestinal tissues to be effective. Oral corticosteroids are potent anti-inflammatory agents. After absorption, corticosteroids exert prompt anti-inflammatory action throughout the body. Consequently, they are used in treating Crohn’s enteritis, ileitis, and ileocolitis, as well as ulcerative and Crohn’s colitis. In critically ill patients, intravenous corticosteroids (such as hydrocortisone) can be given in the hospital.
Corticosteroids are faster acting than the 5-ASA compounds. Patients frequently experience improvement in their symptoms within days of starting corticosteroids. Corticosteroids, however, do not appear to be useful in maintaining remissions in ulcerative colitis.
Corticosteroid side effects
Side effects of corticosteroids depend on the dose and duration of use. Short courses of prednisone, for example, usually are well tolerated with few and mild side effects. Long term, high doses of corticosteroids usually produce predictable and potentially serious side effects. Common side effects include rounding of the face (moon face), acne, increased body hair, diabetes, weight gain, high blood pressure, cataracts, glaucoma, increased susceptibility to infections, muscle weakness, depression, insomnia, mood swings, personality changes, irritability, and thinning of the bones (osteoporosis) with an accompanying increased risk of compression fractures of the spine. Children on corticosteroids can experience stunted growth.
The most serious complication from long term corticosteroid use is aseptic necrosis of the hip joints. Aseptic necrosis means death of bone tissue. It is a painful condition that can ultimately lead to the need for surgical replacement of the hips. Aseptic necrosis also has been reported in knee joints. It is unknown how corticosteroids cause aseptic necrosis.
Prolonged use of corticosteroids can depress the ability of the body’s adrenal glands to produce cortisol (a natural corticosteroid necessary for proper functioning of the body). Abruptly discontinuing corticosteroids can cause symptoms due to a lack of natural cortisol (a condition called adrenal insufficiency). Symptoms of adrenal insufficiency include nausea, vomiting, and even shock. Withdrawing corticosteroids too quickly also can produce symptoms of joint aches, fever, and malaise. Therefore, corticosteroids need to be gradually reduced rather than abruptly stopped.
Long-term use of corticosteroids such as prednisolone or prednisone can cause osteoporosis . Corticosteroids cause decreased calcium absorption from the intestines and increased loss of calcium from the kidneys and bones. Increasing dietary calcium intake is important but alone cannot halt corticosteroid-induced bone loss. Management of patients on long term corticosteroids should include:
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