Ulcerative colitis is one of the disorders known as inflammatory bowel disease (IBD). Other disorders within this group of conditions include Crohn’s disease and two forms of microscopic colitis called lymphocytic and collagenous colitis.
IBD is characterised by chronic inflammation. Although this inflammation primarily affects the lower part of the digestive tract, the symptoms of these disorders can vary greatly depending on the condition and may also impact other parts of the body.
The inflammation caused by ulcerative colitis is restricted to the mucous lining (mucosa) of the large intestine (colon). This inflammation usually starts in the rectum and can spread from there continuously throughout the entire large intestine. However, in most patients this inflammation is limited to the descending colon (the segment located on the left-hand side of the body). Ulcers are common in the affected parts of the intestines. The disease is characterised by alternating phases of active disease (flare-ups) and phases with no symptoms (remission).
An estimated 30% of ulcerative colitis patients exhibit inflammation of the rectum (proctitis) and/or sigmoid colon (proctosigmoiditis) at the time of their initial diagnosis. Although the spread of the inflammation is limited, patients with ulcerative proctitis nonetheless frequently suffer from debilitating symptoms such as rectal bleeding, fecal urgency, tenesmus, or bowel incontinence. Furthermore, a substantial subset of proctitis patients also experience a unique type of constipation called “proximal constipation”. Unless adequately treated, these symptoms can have a major negative impact on these patients’ quality of life.
The exact causes of ulcerative colitis remain unknown. In general, inflammatory bowel disease (IBD) is thought to be caused by interactions between genetic factors and immunologic factors, as well as between a person’s environment and lifestyle and the bacteria in the gut (microbiota). Although psychological factors and stress may trigger flare-ups in people who already have ulcerative colitis, they are not thought to be underlying causes of the disease based on current research.
It is estimated that about 500 out of every 100,000 residents in Europe suffer from ulcerative colitis (prevalence). However, within Europe as a whole, the disease is more common in northern countries than in southern ones. Although the disease can be diagnosed at any age, the highest number of new cases (incidence) are diagnosed in people between the ages of 25 and 35 years old. Men and women are about equally affected by the disease.
The symptoms of ulcerative colitis can differ depending on several factors, including the extent of inflammation and whether any parts of the body outside of the large intestine are affected. The severity of symptoms is not necessarily an indicator of the severity of inflammation.
The primary symptom of ulcerative colitis is diarrhea containing blood and pus which occurs at night as well as during the day. Other symptoms include abdominal pain, which is often centered at one specific spot in the gut (frequently in the lower left abdomen) but can spread to the entire abdomen. This pain may come in waves or it may be continuous. Additional symptoms include flatulence, feeling the constant need to defecate (called fecal urgency), as well as fever and weight loss in severe cases. The disease typically begins gradually, although some people may also have severe and acute symptoms (called fulminant disease) at the time of their diagnosis.
Ulcerative colitis may also cause very general symptoms like reduced strength, fatigue, or loss of appetite. Due to the persistent bloody diarrhea, patients may develop anemia (low red blood cell counts) over time.
Some patients with ulcerative colitis also experience symptoms in other parts of their body, which are called extraintestinal manifestations. These may impact the liver, bile ducts, pancreas, skin, eyes, and joints. The types and extent of these extraintestinal manifestations sometimes reflect the course of the underlying ulcerative colitis, but this is not always the case. Extraintestinal manifestations may even cause symptoms before the actual inflammation of the digestive tract has started.
Most complications appear in patients whose ulcerative colitis has spread throughout the entire large intestine (pancolitis). Severe bleeding and a hole in the large intestine caused by narrowing (perforated colon) are fortunately rare, acute complications that usually require urgent care.
Compared to the healthy population, people with ulcerative colitis have a higher risk of developing colorectal cancer. This risk goes up the earlier the disease starts, the longer it lasts, and the more the inflammation has spread. For these reasons, patients who have already had ulcerative colitis for 10 to 15 years should undergo regular colorectal cancer screening (colonoscopy).
Someone is suspected of having ulcerative colitis if they present with the symptoms described above. In order to confirm this suspected diagnosis, the prior medical history needs to be assessed, a clinical examination will be performed, and several other diagnostic tests carried out.
The purpose of collecting the medical history of the patient is to find out his or her current symptoms, how long they last, and how intense they are.
Also any other symptoms that might indicate inflammation outside of the intestines (extraintestinal manifestations) will be assessed.
During a physical examination, the doctor touches and presses against the abdomen and examines the rectum. Listening to abdominal sounds or tapping organs can provide initial indications of changes inside the abdomen.
Other laboratory tests may be performed to gather additional information. These tests can include general blood tests as well as tests for inflammation parameters like the C-reactive protein (CRP). An analysis of gut bacteria may also be needed. These tests can be combined with other ones like the erythrocyte sedimentation rate (ESR) to collect information about the intensity of the inflammation. Doctors also frequently test a stool sample for the level of calprotectin, and may also check for autoantibodies in the serum if the stool test is inconclusive.
The physical examination will also look for possible extraintestinal manifestations or extraintestinal complications (such as gallstones, kidney stones, or osteoporosis).
Physical examinations should be performed regularly to evaluate the progression of the disease or the effects of any medications.
If a patient’s medical history and physical examination provide indications of ulcerative colitis, the diagnosis will be confirmed using imaging procedures. The most common procedures used to diagnose ulcerative colitis are ultrasound and colonoscopy. During the latter one tissue samples (biopsies) can be collected for examination under a microscope.
In special cases, additional tests like an X-ray of the abdomen may be necessary. The doctor may also order a CT (computed tomography) or MRI (magnetic resonance imaging) scan to clarify specific issues.
Treatment of ulcerative colitis depends on the type of symptoms and their severity as well as the degree of inflammation and how far the disease has spread. The goal of treatment is to suppress the inflammation and to allow the mucosa to recover as much as possible, as well to prevent the inflammation from flaring back up while the disease is in remission (maintenance of remission).
Medication is usually the primary method of treatment, with the drug mesalazine being the 1st line recommendation in treatment guidelines for mild to moderate flare-ups. This drug is available in several different forms for oral or rectal application.
During a severe acute flare-up, corticosteroid drugs (usually just called steroids) are also prescribed in order to quickly suppress the inflammation and to allow the intestines to return to a period without symptoms (induction of remission). While systemic steroids are active in the entire body, the drug budesonide is a better-tolerated option. Several galenic formulations of budesonide have been developed specifically to treat gastrointestinal disorders. The advantage of these topical formulations is the fact that they are active only in the intestines, where the disease occurs. Budesonide is then transported from the gut into the liver, where it is broken down. These properties mean that budesonide causes much less side effects than systemic steroids do.
The recommended first-line pharmacological treatment options for ulcerative proctitis are mesalazine delivered in a rectal dosage form, or a topical corticosteroid (e.g. budesonide) delivered as a suppository, enema, or rectal foam.
If mesalazine and steroids are not able to relieve symptoms, other medications can be used which suppress the activity of the immune system (immunosuppressants) or which switch off specific signaling molecules that promote inflammation (biologics).
Even after symptoms have resolved, patients still need to take medications to ensure that the successful outcome of the initial treatment is sustained for as long as possible (maintenance therapy).
Although there is no special diet for inflammatory bowel disease, nutrition plays an important role in the condition. Many patients experience malnutrition due to their loss of appetite, diarrhea, and weight loss, or they suffer from major vitamin and mineral deficiencies. It might therefore be necessary to take supplements for any nutrients found to be deficient.
Even without nutritional deficiencies, a balanced diet with easily-digestible foods is recommended for all patients with ulcerative colitis. However, any foods that are not tolerated well should be avoided (for example foods that cause bloating and gas). It may be helpful to keep a food diary.
About three-quarters of all patients with ulcerative colitis can be successfully treated with medications. However, some patients do not adequately respond to the medications described here and never achieve remission. In these cases, surgery – usually involving removal of the entire large intestine (colectomy) – may be a possible option.
During this operation, a small pouch is typically formed from loops of the small intestine which then acts as a replacement for the rectum. This pouch is connected to the anus so that patients do not require an artificial anus (stoma) to empty their bowels. However, a temporary stoma may still be necessary while the abdomen recovers from the initial surgery. This stoma is then re-closed during a second operation, and a natural intestinal pathway is restored to the greatest extent possible.
If an inflammatory bowel disease results in nutritional deficiencies or malnutrition, vitamin and mineral supplements may be necessary (see Dietary therapy).
As with almost all chronic diseases, ulcerative colitis can represent a significant psychological burden, especially when a stoma is required. Special support for handling such unusual situations is available, and psychotherapy to assist in managing the disease may be advisable. The ability to meet and exchange experiences with other ulcerative colitis patients in self-help groups or other platforms can also be helpful.
Outlook and prognosis
Ulcerative colitis usually comes in waves, alternating between flare-ups of acute inflammation and phases with no symptoms. Most patients are able to successfully suppress the acute flare-ups using targeted medication. However, since these drugs do not cure the disease, there is always a theoretical possibility that the inflammation will flare up again. Adherence to maintenance therapy, therefore, is significantly relevant. Surgical removal of the large intestine greatly improves quality of life for most patients, even in light of the possibility that the pouch at the end of the small intestine may become inflamed (pouchitis).
It is not possible to predict how the disease will progress in any individual patient, but instead requires observation over time.
Another issue that must be kept in mind is the risk of colorectal cancer. Regular cancer screening is therefore very important to detect cancer as well as pre-cancerous forms and, if present, to start treating them as soon as possible including the removal of any unusual growths (like polyps) from the large intestine.