Ulcerative colitis

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Other names: colitis gravis idiopathic proctocolitis inflammatory bowel disease, ulcerative colitis type UC

Ulcerative colitis is a chronic, or long lasting, disease that causes inflammation—irritation or swelling—and sores called ulcers on the inner lining of the large intestine.

Ulcerative colitis is a chronic inflammatory disease of the gastrointestinal (GI) tract, called inflammatory bowel disease (IBD). Crohn's disease and microscopic colitis are the other common IBDs.

Ulcerative colitis most often begins gradually and can become worse over time. Symptoms can be mild to severe. Most people have periods of remission—times when symptoms disappear—that can last for weeks or years. The goal of care is to keep people in remission long term.

Most people with ulcerative colitis receive care from a gastroenterologist, a doctor who specializes in digestive diseases.

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Cause

The exact cause of ulcerative colitis is unknown. Researchers believe the following factors may play a role in causing ulcerative colitis:

  • overactive intestinal immune system
  • genes
  • environment

Overactive intestinal immune system: Scientists believe one cause of ulcerative colitis may be an abnormal immune reaction in the intestine. Normally, the immune system protects the body from infection by identifying and destroying bacteria, viruses, and other potentially harmful foreign substances. Researchers believe bacteria or viruses can mistakenly trigger the immune system to attack the inner lining of the large intestine. This immune system response causes the inflammation, leading to symptoms.

Genes: Ulcerative colitis sometimes runs in families. Research studies have shown that certain abnormal genes may appear in people with ulcerative colitis. However, researchers have not been able to show a clear link between the abnormal genes and ulcerative colitis.

Environment: Some studies suggest that certain things in the environment may increase the chance of a person getting ulcerative colitis, although the overall chance is low. Nonsteroidal anti-inflammatory drugs,1 antibiotics,1 and oral contraceptives2 may slightly increase the chance of developing ulcerative colitis. A high-fat diet may also slightly increase the chance of getting ulcerative colitis.3

Some people believe eating certain foods, stress, or emotional distress can cause ulcerative colitis. Emotional distress does not seem to cause ulcerative colitis. A few studies suggest that stress may increase a person's chance of having a flare-up of ulcerative colitis. Also, some people may find that certain foods can trigger or worsen symptoms.

Inheritance

The inheritance pattern of ulcerative colitis is unknown because many genetic and environmental factors are likely to be involved. Even though the inheritance pattern of this condition is unclear, having a family member with ulcerative colitis increases the risk of developing the condition.

Risk factors

Ulcerative colitis can occur in people of any age. However, it is more likely to develop in people

  • between the ages of 15 and 304
  • older than 601
  • who have a family member with IBD
  • of Jewish descent

Signs and symptoms

Classification of Colitis.jpg

The most common signs and symptoms of ulcerative colitis are diarrhea with blood or pus and abdominal discomfort. Other signs and symptoms include

  • an urgent need to have a bowel movement
  • feeling tired
  • nausea or loss of appetite
  • weight loss
  • fever
  • anemia—a condition in which the body has fewer red blood cells than normal

Less common symptoms include

  • joint pain or soreness
  • eye irritation
  • certain rashes

The symptoms a person experiences can vary depending on the severity of the inflammation and where it occurs in the intestine. When symptoms first appear,most people with ulcerative colitis have mild to moderate symptoms about 10 percent of people can have severe symptoms, such as frequent, bloody bowel movements; fevers; and severe abdominal cramping.

Diagnosis

A health care provider diagnoses ulcerative colitis with the following:

  • medical and family history
  • physical exam
  • lab tests
  • endoscopies of the large intestine

The health care provider may perform a series of medical tests to rule out other bowel disorders, such as irritable bowel syndrome, Crohn's disease, or celiac disease, that may cause symptoms similar to those of ulcerative colitis.

Medical and Family History

Taking a medical and family history can help the health care provider diagnose ulcerative colitis and understand a patient's symptoms. The health care provider will also ask the patient about current and past medical conditions and medications.

Physical Exam

A physical exam may help diagnose ulcerative colitis. During a physical exam, the health care provider most often

  • checks for abdominal distension, or swelling
  • listens to sounds within the abdomen using a stethoscope
  • taps on the abdomen to check for tenderness and pain

Lab Tests

A health care provider may order lab tests to help diagnose ulcerative colitis, including blood and stool tests. Blood tests. A blood test involves drawing blood at a health care provider's office or a lab. A lab technologist will analyze the blood sample. A health care provider may use blood tests to look for

  • anemia
  • inflammation or infection somewhere in the body
  • markers that show ongoing inflammation
  • low albumin, or protein—common in patients with severe ulcerative colitis

Stool tests. A stool test is the analysis of a sample of stool. A health care provider will give the patient a container for catching and storing the stool at home. The patient returns the sample to the health care provider or to a lab. A lab technologist will analyze the stool sample. Health care providers commonly order stool tests to rule out other causes of GI diseases, such as infection.

Endoscopies of the Large Intestine

Endoscopies of the large intestine are the most accurate methods for diagnosing ulcerative colitis and ruling out other possible conditions, such as Crohn's disease, diverticular disease, or cancer. Endoscopies of the large intestine include

Colonoscopy. Colonoscopy is a test that uses a long, flexible, narrow tube with a light and tiny camera on one end, called a colonoscope or scope, to look inside the rectum and entire colon. In most cases, light anesthesia and pain medication help patients relax for the test. The medical staff will monitor a patient's vital signs and try to make him or her as comfortable as possible. A nurse or technician places an intravenous (IV) needle in a vein in the patient's arm or hand to give anesthesia.

For the test, the patient will lie on a table or stretcher while the gastroenterologist inserts a colonoscope into the patient's anus and slowly guides it through the rectum and into the colon. The scope inflates the large intestine with air to give the gastroenterologist a better view. The camera sends a video image of the intestinal lining to a monitor, allowing the gastroenterologist to carefully examine the tissues lining the colon and rectum. The gastroenterologist may move the patient several times and adjust the scope for better viewing. Once the scope has reached the opening to the small intestine, the gastroenterologist slowly withdraws it and examines the lining of the colon and rectum again.

A colonoscopy can show irritated and swollen tissue, ulcers, and abnormal growths such as polyps—extra pieces of tissue that grow on the inner lining of the intestine. If the gastroenterologist suspects ulcerative colitis, he or she will biopsy the patient's colon and rectum. A biopsy is a procedure that involves taking small pieces of tissue for examination with a microscope.

A health care provider will give patients written bowel prep instructions to follow at home before the test. The health care provider will also give patients information about how to care for themselves following the procedure.

Flexible sigmoidoscopy. Flexible sigmoidoscopy is a test that uses a flexible, narrow tube with a light and tiny camera on one end, called a sigmoidoscope or scope, to look inside the rectum, the sigmoid colon, and sometimes the descending colon. In most cases, a patient does not need anesthesia.

For the test, the patient will lie on a table or stretcher while the health care provider inserts the sigmoidoscope into the patient's anus and slowly guides it through the rectum, the sigmoid colon, and sometimes the descending colon. The scope inflates the large intestine with air to give the health care provider a better view. The camera sends a video image of the intestinal lining to a monitor, allowing the health care provider to examine the tissues lining the sigmoid colon and rectum. The health care provider may ask the patient to move several times and adjust the scope for better viewing. Once the scope reaches the end of the sigmoid colon, the health care provider slowly withdraws it while examining the lining of the colon and rectum again.

The health care provider will look for signs of bowel diseases and conditions such as irritated and swollen tissue, ulcers, and polyps.

If the health care provider suspects ulcerative colitis, he or she will biopsy the patient's colon and rectum.

A health care provider will give patients written bowel prep instructions to follow at home before the test. The health care provider will also give patients information about how to care for themselves following the procedure.


Treatment

A health care provider treats ulcerative colitis with

  • medications
  • surgery

Medications

While no medication cures ulcerative colitis, many can reduce symptoms. The goals of medication therapy are Health care providers will prescribe the medications that best treat a person's symptoms: Depending on the location of the symptoms in the colon, health care providers may recommend a person take medications by

  • enema, which involves flushing liquid medication into the rectum using a special wash bottle. The medication directly treats inflammation of the large intestine.
  • rectal foam—a foamy substance the person puts into the rectum like an enema. The medication directly treats inflammation of the large intestine.
  • suppository—a solid medication the person inserts into the rectum to dissolve. The intestinal lining absorbs the medication.
  • mouth.
  • IV.


Aminosalicylates:Aminosalicylates include

Corticosteroids:Corticosteroids are effective in bringing on remission; however, studies have not shown that the medications help maintain long-term remission. Corticosteroids include

Immunomodulators:Immunomodulators reduce immune system activity, resulting in less inflammation in the colon. These medications can take several weeks to 3 months to start working. Immunomodulators include

Biologics, also called anti-TNF therapies:Biologics—including adalimumab, golimumab, and infliximab—are medications that target a protein made by the immune system called tumor necrosis factor (TNF). These medications decrease inflammation in the large intestine by neutralizing TNF. Anti-TNF therapies work quickly to bring on remission, especially in people who do not respond to other medications. Infliximab is given through an IV; adalimumab and golimumab are given by injection.

Health care providers will screen patients for tuberculosis and hepatitis B before starting treatment with anti-TNF medications.

other medications: Other medications to treat symptoms or complications may include

acetaminophen for mild pain. People with ulcerative colitis should avoid using ibuprofen, naproxen, and aspirin since these medications can make symptoms worse.

antibiotics to prevent or treat infections. loperamide to help slow or stop diarrhea. In most cases, people only take this medication for short periods of time since it can increase the chance of developing megacolon. People should check with a health care provider before taking loperamide, because those with significantly active ulcerative colitis should not take this medication. cyclosporine—health care providers prescribe this medication only for people with severe ulcerative colitis because of the side effects. People should talk with their health care provider about the risks and benefits of cyclosporine.

Removal of the entire colon, including the rectum, "cures" ulcerative colitis. A surgeon performs the procedure at a hospital. A surgeon can perform two different types of surgery to remove a patient's colon and treat ulcerative colitis:

Epidemiology

Ulcerative colitis is most common in North America and Western Europe; however the prevalence is increasing in other regions. In North America, ulcerative colitis affects approximately 40 to 240 in 100,000 people. It is estimated that more than 750,000 North Americans are affected by this disorder. Ulcerative colitis is more common in whites and people of eastern and central European (Ashkenazi) Jewish descent than among people of other ethnic backgrounds.

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