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Ulcerative Colitis

What is Ulcerative Colitis (UC)?

Ulcerative Colitis is one of two main diseases that fit into a disease category called Inflammatory Bowel Disease or IBD. In these types of diarrhea, the body’s own immune system is recognizing parts of the GI tract as foreign and mounting a response. In Ulcerative Colitis, the attack is mainly on the colon, but in the sister disease, Crohn’s, the disease can attack anywhere from mouth to anus.

The incidence of Ulcerative Colitis has been increasing in America, now up to 24 cases per 100,000 people.

Nobody knows what triggers the body to recognize its lining as foreign. There are thought to be genetic factors as well as exposure to an inciting stimulus that “turn on” the immune system. Both UC and Crohn’s are less prevalent in countries where food sources are less sterile/processed. Industrialized diet, smoking, antibiotics, and stress all may play some role. About 15-30% of patients have other family members afflicted.

Ulcerative colitis involves inflammation that starts in the rectum and the more superficial layers of the wall extending up the colon. The disease varies from Ulcerative Proctitis involving the rectum to left sided UC or Pan-Ulcerative Colitis if it involves the whole colon. Treatments will vary depending on the amount of tissue involved.

Because of the chronic nature of this condition, the disease rarely “goes away”, although with age it can “burn itself out”, becoming less prominent over time.

What are the symptoms of Ulcerative Colitis?

Most often, symptoms of Ulcerative Colitis involve rectal bleeding and pain. Despite treatment, these episodes will exacerbate or “flare”, and then go away for weeks or months. Initial symptoms can be vague and mimic intestinal flu, so diagnosis is often delayed.

  • The abdominal pain may be mostly in the left lower abdomen or involve the entire belly
  • Fever and chills can be present—predisposition to infection is increased
  • Weight loss is seen in 65-75% of patients
  • Anemia may be noted on lab analysis
  • Diarrhea in ulcerative colitis tends to be bloody and painful
  • Liver function tests can increase if patients also develop an associated inflammation of the bile ducts (primary sclerosing cholangitis)
  • Skin redness and ulcers can occur
  • Eye inflammation and light sensitivity can be seen
  • Arthritis is common, particularly where the spine meets the hip
  • Intestinal blockage rarely occurs

Doctor helping man with stomach pain

How is Ulcerative Colitis diagnosed?

Your primary care provider or gastroenterologist may order stool studies to rule out infection and look for parasites and white blood cells.

X-rays or CT scans can be helpful and appraising the level of involvement.

A colonoscopy will be required to check the appearance of the inflammation in the colon and obtain confirmatory biopsies.

There may be blood markers and measure of inflammation that can be checked. For example, a C-reactive protein is a blood marker that corresponds to the overall inflammation in the body (also increases with COVID), and fecal calprotectin levels use the stool to answer the same question. These can be used to monitor for treatment too.

Your gastroenterologist will want to check your colon periodically to look for cancer and other lesions. The risk is about 8% after 20 years and 18% after 30 years.

How is Ulcerative Colitis treated?

There are several non-pharmacologic treatments:

  • Avoid stress as much as practical. Rest is key.
  • Avoid dairy and milk proteins as these can worsen the diarrhea.
  • Avoid excessive fiber in the diet—these are called low residue diets and help the gut cope with the inflammation.
  • Avoid other trigger foods particular to you.

Drugs such as steroids can calm down the inflammation but typically the disease reflares when they are stopped. The same is true of antibiotics.

Special preparations of aspirin like drugs, mesalamine, can be used to calm inflammation. These often require pills once or several times per day.

Immunomodulating agents like methotrexate and azothioprine can work like chemotherapy to blunt the immune response to the gut lining, This has to be balanced against the risk of infection and toxicity.

Newer agents such as biologics like Infliximab (Remicade), Adalimumab (Humira), Vedolizumab (Entyvio), Ustekinumab (Stelara) and Tofacitinib (Xeljanz) can modify the immune response to the disease.

  • They tend to be more effective and rapid acting than other agents.
  • These also can increase the risk of opportunistic infections and very rarely certain types of cancer (PML, and lymphoma/skin cancers).
  • They can be more expensive than the other agents.

About 20% of UC patients end up requiring surgery if no relief with medications is seen.

  • Surgery may involve a partial or complete removal of the colon.
  • In select individuals, a reservoir can be fashioned out of small bowel to maintain fecal continence, but with an increased number of stools per day.
What to do if you suspect you have Ulcerative Colitis?

See your local gastroenterologist to help make the diagnosis and start you on a therapy that is right for you. Our goal is give you therapy that results in long-lasting remissions, maintenance of your independence, and a better quality of life while minimizing medication side effects.

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