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What is ulcerative colitis?
Ulcerative colitis (UC) is a form of inflammatory bowel disease (IBD) where your large bowel, also known as the colon’ inner lining becomes inflamed and ulcerated (affected by ulcers). Sometimes the inflammation or soreness in the lining of the bowel only involves the very end of the bowel (rectum) and this is known as proctitis. Sometimes the inflammation goes further along the left side of the colon (left sided colitis), and in some people the entire large bowel is involved (pancolitis).
How common is ulcerative colitis?
It’s estimated that ulcerative colitis affects about one in every 300-400 people. It’s more common in urban rather than rural areas. The numbers are beginning to increase in developing nations. Ulcerative colitis affects women and men equally. It tends to develop more frequently in non-smokers and ex-smokers than smokers. However, health professionals consider the risks of smoking heavily outweigh any benefits seen in ulcerative colitis, and strongly discourage smoking in everyone, whether or not they have inflammatory bowel disease.
What causes ulcerative colitis?
It is unknown what causes ulcerative colitis, however what is known is that the body’s immune system is acting inappropriately by attacking itself and causing the bowel inner lining to become red and inflamed, swollen and causing ulcers which can secrete excess mucous and bleed. Sometimes the disease will jump start due to an unknown 'trigger' or set of triggers that could include viruses, other bacteria, diet, stress, or something else in the environment. There is also a genetic element to ulcerative colitis and that IBD can run in families. Its not infective so you cannot get it from others or give it to other people.
What are the symptoms?
Symptoms may vary from mild to severe and will vary from person to person. Some people can remain well for a long time, even for many years, while others have frequent flare-ups. They may also change over time, with periods of good health when you have few or no symptoms (remission), alternating with times when your symptoms are more active (relapses or ‘flare-ups’).
The main symptom of ulcerative colitis is mucous (and bloody) diarrhoea. You may experience pain in your abdomen and feel very unwell. Sometimes you may have cramping pains in the abdomen. These can be very severe and often occur before passing a stool. You may also feel an urgency to open your bowels (have to rush to the toilet) this may happen a number of times during the day or night. You may also feel tired. Sometimes you may feel mildly feverish. You may lose your appetite and lose weight. Other parts of the body can occasionally be affected such as your joints (causing painful joints) skin (causing a tender rash on your shins) and your eyes (painful, gritty and red eyes). Very rarely the liver can get affected causing yellow discolouration of the skin and eyes.
How to assess the severity of ulcerative colitis
- Mild: Bowel movements fewer than 4 per day with no more than small amounts of blood in stools without fever, pulse rate less than 90, no anaemia, ESR less than 30
- Moderate: Bowel movements 4 - 6 per day with with no more than small amounts of blood in stools without fever, pulse rate less than 90, no anaemia, ESR less than 30
- Severe: Bowel movements more than 6 per day with visible blood in stools with fever or pulse rate higher than 90 or anaemia or ESR higher than 30
- Fulminant: Bowel movements more than 10 per day with visible blood in stools with fever or pulse rate higher than 90 or anaemia or ESR higher than 30 with severe abdominal pain
How is it diagnosed?
After listening to a complete history of the disease and examining you, the doctor will arrange a colonoscopy and some blood and stools tests for you in order to come in to a diagnosis.
Diagnosis is usually achieved by careful consideration of many clues in history, examination, colonoscopic view, biopsy results and blood tests. Mainly, if you have classic features of ulcerative colitis symptoms in the history with or without family history, along with suggestive colonoscopic features which is confirmed by biopsy analysis, the diagnosis is certain. However, all these features are not always present and careful interpretation of results by a specialist is mandatory.
The severity of the disease is also can be determined by analysing the history, colonoscopic findings, biopsy results and laboratory tests.
Can ulcerative colitis lead to bowel cancer?
Ulcerative colitis is not a form of cancer. However if you have had extensive or total colitis (pancolitis) for many years, you have a greater risk than normal of developing cancer in the colon or rectum. This increased risk is not as great for people with partial colitis. Research shows that this risk of developing cancer usually begins to increase about 8-10 years after the start of the inflammatory bowel disease symptoms. (This is not from the date of your diagnosis, which could be much later than when your symptoms started). Having Primary Sclerosing Cholangitis (PSC) may also increase your risk of bowel cancer.
It is possible to develop pre-cancerous lesions in the inner lining of the large bowel before the growth of an actual tumour. Therefore, you may need surveillance colonoscopy based on current guidelines and recommendations. However, the overall number of people with inflammatory bowel disease who develop bowel cancer is very small, and cancers can often be more successfully treated if detected early.
What treatments are available?
Medications aim to improve your symptoms by settling the inflammation in the bowel. Ulcerative colitis is most commonly treated with a medication called sulphasalazine or mesalazine. They comes in tablet forms to swallow, as well as treatments that can be administered via your back passage. It is likely you will need to stay on a low maintenance dose of this drug long term, this varies from patient to patient.
You may also be given a short courses of steroids initially to get the disease under control rapidly or if your symptoms are increasing despite your usual medications (a flare in your disease). Steroids can also be applied as a suppository or as an enema.
Some patients require extra medication (e.g. azathioprine) to suppress the immune system slightly and stop it fighting against the bowel. Consult your doctor for more information regarding this if you wish.
If your disease is not responding to usual medication or if you cannot be without steroids, you may need medications known as “Biologics” such as infliximab or adalimumab.
Apart from the specific medication, there are supportive medication too. These help to control and reduce common symptoms such as pain, diarrhoea and constipation. They include:
- Anti-diarrhoeals such as Loperamide (Imodium)
- Laxatives such as Movicol and Lactulose
- Bulking agents such as Fybogel
- Analgesics (pain killers) such as paracetamol.
Surgery may become necessary if the inflammation is very severe, and in some other situations. Surgery may also be recommended if dysplasia (pre-cancerous changes) or cancer is found in your colon during a colonoscopy. More rarely, people with very severe ulcerative colitis which does not respond to intensive medical treatment will need urgent surgery (within a few days) or emergency surgery (within a few hours). After surgery, you’ll either undergo a restorative surgery (Restorative proctocolectomy and illeo pouch anal anastomosis) by having a neo-rectum - a J shaped pouch made with small bowel joined to your anus (in which case you go to toilet from your anus as usual) or you may be left with a permeant stoma.
What about the diet?
There has been extensive research into diet as a possible cause or trigger of ulcerative colitis, but so far there are no clear answers and there is little evidence that diet plays a role in ulcerative colitis. Generally, the most important thing is to eat a nutritious and balanced diet to maintain your weight and strength, and to drink sufficient fluids to stop you getting dehydrated.
Is there a cure?
The only current potential cure is to surgically remove the entire colon and the rectum leaving the small bowel. In a small proportion of people, medications do not settle the inflammation in the bowel and an operation is needed. This is sometimes the best way of ensuring you are feeling fit and well.