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Ulcerative ColitisPatient Education > Colon/Rectal > Ulcerative Colitis General Discussion:Ulcerative Colitis is a non-specific inflammatory disease of the bowel characterized by chronic ulceration. The most common presenting symptom of this disorder is bloody diarrhea. This disease generally begins in the rectosigmoid area. It may involve only the left side of the colon or may eventually extend to involve the entire bowel. However, in some cases it may attack most of the large bowel simultaneously. The disease is usually chronic with repeated periods of exacerbation and remission. Ulcerative colitis is an acute nonspecific inflammation of the colon characterized by multiple, irregular superficial ulcerations. Thickening of the wall of the colon with scar tissue and polyp-like structures are the result of prolonged inflammatory reactions.
Symptoms: The symptoms of ulcerative colitis may first include malaise, weakness, and fatigue. A vague abdominal discomfort may be associated with a slight change in the frequency and consistency of stools. Later, there may be pain along with cramping in the abdomen, urgency (tenesmus), anorexia, loss of weight, and abdominal distention may also be present. Ulcerative colitis generally causes bloody diarrhea which vary in intensity and duration, followed by intervals when the patient feels relatively normal. There is an increased urgency to defecate, mild cramps in the lower abdomen, and the stools may contain mucus and blood. However, in some cases the onset of the attack may be explosive with acute symptoms. In this instance, episodes of diarrhea may be sudden and violent. Patients may develop high fever, signs of peritonitis (inflammation of the membrane lining of the abdominal cavity) and a profound toxic state may exist. Causes:The exact cause of Ulcerative Colitis is unknown. The disorder may be related to exposure to infection or immunological agents, or may be caused by an unknown environmental agent. There is a documented familial tendency. Studies of the incidence of Ulcerative Colitis and Crohn's Disease indicate that relatives of people with either of these inflammatory bowel disease has a ten-fold increased risk of developing the disease. This study suggests that the cause of both disorders may be genetic. Psychological factors may also have an effect on this disorder, but are not considered a cause.
Affected Population:Ulcerative colitis may begin at any age, but its peak incidences is between the age of 20 and 25. There is also an increase in frequency in the fifth and sixth decades of life. The disease is more prevalent among Jews, but all ethnic groups appear to be at risk. Medical Therapies for Ulcerative Colitis: The treatment for Ulcerative Colitis depends upon the severity of the disease. Mild forms of the disease may be managed with nonspecific supportive measures. These include adequate physical and emotional relaxation. The patients may follow a normal diet, refraining only from the roughage in raw fruits and vegetables. Approximately one third of the patients find milk an irritant and it should also be eliminated. Anti-diarrhea agents may also be necessary. Sulfasalazine (Azulfidine) may be used in mild to moderate forms of the disease. In order to reduce gastrointestinal side effect of the drug (nausea, indigestion, and anorexia); it should be taken with meals and the dosage increased gradually by the patient's physician. Other agents now available include 5 ASA medications such as Mesalamine (Asacol, Rowasa, Pentasa) and Olsalazine Sodium (Dipentum). In cases of either mild or moderate severity, hydrocortisone (steroid) enemas may occasionally be effective in achieving remission especially if the disease is located in the rectum or left colon. If the disease is severe, corticosteroid therapy may be indicated. Intensive therapy with Prednisone (steroid) frequently induces remission. Sulfasalazine or 5 ASA medications may be given to the patient in conjunction with Prednisone. After improvement, it may be possible to gradually taper the dosage of the corticosteroid and ultimately withdraw it. Chronic fecal blood loss may require iron in order to prevent anemia. The more severe attacks of Ulcerative Colitis may require hospitalization and IV corticosteroid and nutrition. When remission has been obtained, oral Prednisone therapy may be substituted, then gradually reduced after continued improvement. Immunosuppressive drugs such as azathioprine (Imuran) and 6-metacaptopurine have also been used to treat patients with this disorder.
Cancer and Ulcerative Colitis:Colorectal cancer occurs more frequently among patients with Ulcerative Colitis than in the general population. Colorectal cancer tends to occur late in the disease course, usually ten or more years after onset. Cancer risk is highest in those with extensive or pan colitis. There is little or no increased risk of cancer associated with proctitis (involvement of the rectum only), proctosigmoiditis (involvement of the rectum and sigmoid colon only). There is slight to moderate increase of colon cancer in patients with left sided colitis (involving rectum, sigmoid, and descending colon). Cancer in colitis can be prevented by surgical removal of the large intestine. There is controversy about how often one's colon should be surveyed by colonoscopy, sigmoidoscopy, or barium enema for detection of precancerous change or carcinoma at a surgically curable stage. Vigorous medical treatment against the inflammation of Ulcerative Colitis may reduce cancer risk. Cancer complicating colitis is not necessarily fatal. The overall survival rate is similar to that of colorectal cancer in the general population; the survival rate depends on tumor invasion through the wall, presence of lymph node, or distant organ metastasis. Colonoscopy: It is important to define the extent of inflammation in patients with Ulcerative Colitis. Treatment, prognosis, and cancer risk are defined by the extent of involvement of the colon. In patients with normal colons, polyps and tumors are clearly distinguishable from surrounding normal intestinal lining. The inflammatory change in Ulcerative Colitis makes it more difficult for the endoscopist to recognize polyps or small tumors. It is therefore necessary to often perform multiple biopsies during surveillance colonoscopies. Detection for abnormal cell growth (dysplasia) is currently the main method used for detection of precancerous change. Any patient with a retained rectum or distal colon after acute surgical treatment should undergo annual endoscopy with biopsy of the remnant.
Surgery for Ulcerative Colitis: The only permanent cure for ulcerative colitis is surgery. This may require total proctocolectomy (removal of entire colon and rectum) with permanent ileostomy or ileal-anal pull through. Between 20-30% of patients ultimately undergo this operation. The indications for surgery vary among patients. The timing and choice of surgery must be individualized. Absolute Surgical Indications:Three absolute and non debatable indications for immediate surgery are: 1) Massive hemorrhage; 2) Colon perforation; 3) Colon Cancer. Rectal bleeding is often the early and very common manifestation of Ulcerative Colitis. Massive bleeding is relatively unusual. Ten percent of urgent colectomies are prompted by severe hemorrhage. Subtotal colectomy is a reasonable option. Attempts are made to preserve the rectum for possible future mucosal stripping and ileoanal anastomosis although greater than ten percent will experience hemorrhage from the retained rectal segment. The most reliable procedure is total proctocolectomy with ileostomy. Perforation is the most dreaded and lethal complication of ulcerative colitis. Mortality rates can reach up to fifty percent. It occurs most frequently in the presence of toxic megacolon, although toxic megacolon is not a requisite for the development of perforation. It is important to remember that the patient's colon does not have to dilate in order to perforate. It is important to prevent perforation by treating fulminate colitis aggressively. Aggressive medical treatment including massive doses of steroids can make perforation difficult to recognize in a debilitated patient. Surgery for perforation usually entails abdominal (subtotal) colectomy with rectosigmoid mucous fistula or Hartman's pouch. A conventional ileostomy is performed. Colonoscopic biopsies or barium studies of carcinoma require surgery. Any long standing colonic stricture in ulcerative colitis is considered malignant until proved otherwise. Definitive total proctocolecotmy is advised.
Relative Surgical Indications: Some indications for surgery in Ulcerative Colitis are less absolute; however, the majority of surgeons and non-surgeons treating Ulcerative Colitis agree compelling indications for colectomy include persistent toxic dilatation of the colon, disabling extra colonic manifestations of Ulcerative Colitis, and intractable chronic disease. These are termed relative indications. The type, timing, and alternative management approaches are sometimes debated but generally agreed upon by surgeons and non-surgeons alike. Three relative indications for surgery: Toxic megacolon is a late complication of toxic colitis and may lead to perforation. If colitis is not responding to medical treatment, and dilatation is developing despite mechanical decompression, surgery is indicated. The choice of operation is severely limited during toxic episodes. Subtotal colectomy with rectosigmoid mucous fistula or Hartman's pouch and conventional ileostomy are undertaken. Completion proctectomy could be considered later or possibly future mucosal stripping and ileoanal anastomosis.
Intractable chronic disease after failed medical management, reflected by chronic physical disability and psychosocial dysfunction, is the most frequent indication for surgery in Ulcerative Colitis. This indication is also one of the hardest to define. A standard definition usually involves severe and persistent impairment of a patient's quality of life, at home or at work, created by the disease and/or by the treatment required for the disease. Such problems include frequent hospitalization, social isolation from constant diarrhea, persistent pain and diarrhea with continuous high dose steroids with their toxic side effects. A lifetime of intractable disease can be avoided by surgical removal of the colon. Controversial Surgical Indications: A final group of surgical indications are controversial and not well defined. Prophylactic colectomy (removing the colon when the patient is feeling well) is occasionally considered in patients with long standing Ulcerative Colitis after ten or more years of disease. The finding of definite high grade dysplasia on colonoscopic biopsy may be an indication of concurrent or impending cancer. Some authorities advocate aggressive medical therapy with repeat biopsy. However, there is a dangerous risk of creating a false sense of security if the dysplastic lesion happens to be missed on repeat sampling. Some authors believe any type of dysplasia that is definite and not associated with inflammation should point to colectomy. This leads to controversy as to how patients should undergo colonoscopy. Statistically, the cancer risk begins ten years following the onset of diagnosis. The annual hazard rate for dysplasia or cancer increases with increased duration of the disease. Screening colonoscopy intervals should become shorter rather than longer as the years go by.
Prognosis:The prognosis of Ulcerative Colitis is uncertain. While in most cases the disease is chronic with repeated exacerbations and remissions, complete recovery has occurred after a single attack in about ten percent of patients. The disease may be more severe when the onset occurs after sixty years of age. Possible complications of the disease may include arthritis, inflammation of the tissues surrounding the bile ducts known as pericholangitis, or inflammation of the vertebrae known as ankylosing spondylitis. Further complications may include abscesses in the rectum or colon, fistulas, or intestinal perforations, and skin and eye disorders. Carcinoma of the colon may develop, but the risk is higher in those patients with universal colitis of more than ten years duration. . . Crohn's & Colitis Foundation of America Mailing Address - National Office: Phone: 800-932-2423 Mailing Address - Michigan Office: Phone: 810-737-0900 . Email: info@ccfa.org WebSite: www.ccfa.org/
National Digestive Diseases Information Clearinghouse National Digestive Diseases Information Clearinghouse . Email: nddic@info.niddk.nih.gov WebSite: digestive.niddk.nih.gov/ File Download: UlcerativeColitis.pdf United Ostomy Associations of America, Inc. To reach UOAA by postal mail, the address is: Toll-free phone number: 800-826-0826 . Email: info at uoaa dot org WebSite: www.uoaa.org/ Mayo Clinic - Ulcerative Colitis Site WebSite: www.mayoclinic.com/health/ulcerative-colitis/DS00598
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