Ulcerative colitis (UC) is a chronic inflammatory disease of the colon. The mucosa (inner lining) of the rectum is always inflamed in UC, but the condition may also extend “upstream” to involve the sigmoid colon, descending colon, transverse colon, or the entire colon (pancolitis). (Carter MJ, et al. Guidelines for the management of inflammatory bowel disease in adults. Gut 2004;53(suppl 5):V1-16)
UC affects a half-million Americans. Disease onset is most common between 15 and 40 years of age, with a second peak in incidence between 50 and 80 years. Men and women are affected equally.
The cause of UC is unknown. It is believed that some primary insult to the colon’s mucosa incites a heightened immunologic response to normal gut flora. (Strober W, et al. The fundamental basis of inflammatory bowel disease. J Clin Invest 2007;117:514-21)
Signs and Symptoms of Ulcerative Colitis
The classic presentation of UC is characterized by intermittent bloody diarrhea, rectal urgency, and tenesmus (the constant sensation of a need to empty the bowel, often accompanied by pain). The severity of symptoms usually mirrors the extent of colonic involvement.
25% of UC patients have "extra-colonic" manifestations:
- Osteoporosis (15% of patients)
- Oral ulcerations (10%)
- Arthritis (5-10%)
- Primary sclerosing cholangitis (3%): Beading, scarring, and narrowing of the liver’s bile ducts; may lead to cirrhosis and liver failure
- Uveitis (0.5-3%): Inflammation of the vascular layer of the eye
- Pyoderma gangrenosum (0.5-2%): Ulcers of the skin, usually on the legs
- Deep venous thrombosis ((0.3%): Blood clots in the deep veins of the extremities
- Pulmonary embolism (0.2%): Clots that travel to the lungs
Diagnosis of Ulcerative Colitis
Colonoscopy with biopsy is the “gold standard” test for diagnosis of UC. However, UC must be differentiated from other possible causes of bloody diarrhea, so additional evaluations may include:
- Stool examinations for parasites, bacteria, and toxins
- Blood tests to measure inflammation (CRP, erythrocyte sedimentation rate), electrolytes and liver function, and cell counts
- Additional blood tests to measure specific antibody levels are ordered by some specialists
Treatment of Ulcerative Colitis
The acute management of UC involves control of ongoing inflammation. Two-thirds of patients will achieve remission with medical therapy, and 80% of those patients will maintain remission if they continue therapy.
Current therapies include:
- 5-aminosalicyclic acid (Azulfidine, Mesalamine): Taken orally or rectally. May cause white blood cell abnormalities, diarrhea, headache, rash (including potentially fatal Stevens-Johnson syndrome), renal impairment
- Prednisone: General immune suppressant. May cause adrenal insufficiency, increased blood glucose, osteoporosis
- Steroid enemas
- Azathioprine (Imuran) and Mercaptopurine: Immunosuppresants that inhibit the production of white cells. May cause liver toxicity, headache, diarrhea, muscle aches, decreased white cell count
- Infliximab (Remicaide): A monoclonal antibody that blocks the action of inflammatory immune molecules. May cause joint and muscle pain, fever, lymphoma, central nervous system damage, blood disorders (sometimes fatal), liver damage, and increased susceptibility to infection
- Surgery: Patients with UC are at a higher risk for colon cancer. Surgery is indicated when signs of cancer appear. Surgery is also performed when patients don’t respond to maximal medical therapy or when massive hemorrhage, perforation, or other complications occur.
- Complementary therapy: Intriguing but incompletely studied alternative treatments include Lactobacillus and non-pathogenic E. coli. These modalities have shown promise in preliminary investigations.
(Adapted from Langan RC, et al. Ulcerative colitis: diagnosis and treatment. Am Fam Phys 2007;76(9):1323-1330)
Ulcerative colitis is a debilitating autoimmune disease. Its underlying causes are poorly understood; current therapies are relatively effective but fraught with adverse side effects.
Stephen Allen Christensen - Dr. Steve Christensen's writing has appeared in magazines, professional journals, poetry anthologies, and children's books since 1976.
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