Ulcerative colitis is a chronic inflammatory bowel disease in which the large intestine (colon) becomes inflamed and ulcerated (pitted or eroded), leading to flare-ups (bouts or attacks) of bloody diarrhea, abdominal cramps, and fever. The long-term risk of colon cancer is increased compared to people who do not have ulcerative colitis.
- The exact cause of this disease is not known.
- Typical symptoms during flare-ups include abdominal cramps, an urge to move the bowels, and diarrhea (typically bloody).
- The diagnosis is based on a sigmoidoscopy or sometimes a colonoscopy.
- People who have had ulcerative colitis for a long time may develop colon cancer.
- Treatment is aimed at controlling the inflammation, reducing symptoms, and replacing any lost fluids and nutrients.
Ulcerative colitis may start at any age but usually begins before age 30, usually between the ages of 14 and 24. A small group of people have their first attack between the ages of 50 and 70.
Ulcerative colitis usually starts in the rectum (ulcerative proctitis). It may stay confined to the rectum or over time extend to involve the entire colon. In some people, most of the large intestine is affected at once.
Ulcerative colitis usually does not affect the full thickness of the wall of the large intestine and hardly ever affects the small intestine. The affected parts of the intestine have shallow ulcers (sores). Unlike Crohn disease, ulcerative colitis does not cause fistulas or abscesses.
The cause of ulcerative colitis is not known for certain, but heredity and an overactive immune response in the intestine seem to be contributing factors. Cigarette smoking, which seems to contribute to the development and periodic flare-ups of Crohn disease, seems to decrease the risk of ulcerative colitis. However, smoking in order to reduce the risk of ulcerative colitis is ill-advised in light of the many health problems that smoking can cause.
Treatment
- Dietary management and loperamide
- Aminosalicylates
- Corticosteroids
- Immunomodulating drugs
- Biologic agents
- Sometimes surgery
Ulcerative colitis treatment aims to control the inflammation, reduce symptoms, and replace any lost fluids and nutrients.
Specific treatment depends on the severity of people’s symptoms.
General management of ulcerative colitis
Iron supplements may offset anemia caused by ongoing blood loss in the stool.
Usually, if the large intestine is swollen, people should eat a low-fiber diet (in particular, avoiding foods such as nuts, corn hulls, raw fruits, and vegetables) to reduce injury to the inflamed lining of the large intestine.
A diet free of dairy products may decrease symptoms and is worth trying but does not need to be continued if no benefit is noted.
All people who have ulcerative colitis should take calcium and vitamin D supplements.
Small doses of loperamide are taken for relatively mild diarrhea. For more intense diarrhea, higher doses of loperamide may be needed. In severe cases, however, a doctor must closely monitor the person taking these antidiarrheal drugs because of the risk of fulminant colitis.
Routine health maintenance measures, particularly vaccinations and cancer screening, are important.
Aminosalicylates
Aminosalicylates are drugs used to treat inflammation caused by inflammatory bowel disease. Drugs such as sulfasalazine, olsalazine, mesalamine, and balsalazide are types of aminosalicylates and are used to reduce the inflammation of ulcerative colitis and to prevent flare-ups of symptoms. These drugs usually are taken by mouth (orally), but mesalamine can also be given as an enema or a suppository (rectally). Whether given orally or rectally, these drugs are at best moderately effective for treating mild or moderately active disease, but they are more effective for preventing symptoms from reappearing (maintaining remission).
Corticosteroids
People with moderately severe disease who are not hospitalized usually take oral corticosteroids such as prednisone. Prednisone in fairly high doses frequently induces a dramatic remission. After prednisone controls the inflammation of ulcerative colitis, sulfasalazine, olsalazine, or mesalamine, or an immunomodulating drug or a biologic agent is often is given to maintain the improvement. Gradually, the prednisone dosage is decreased, and ultimately the prednisone is discontinued.
Budesonide is another corticosteroid that may be used. It has fewer side effects than prednisone but does not work as quickly and is typically given to people whose disease is less severe.
When mild or moderate ulcerative colitis is limited to the left side of the large intestine (descending colon) and the rectum, enemas or suppositories with a corticosteroid or mesalamine may be helpful. Corticosteroid treatment is reduced and gradually stopped over several weeks.
If the disease becomes severe, the person is hospitalized, and corticosteroids and fluids are given by vein (intravenously). People may still be given mesalamine. People with heavy rectal bleeding may require blood transfusions.
Immunomodulating drugs
Immunomodulating drugs modify the action of the body’s immune system, decreasing its activity. Drugs such as azathioprine and mercaptopurine have been used to maintain remissions in people with ulcerative colitis who would otherwise need long-term corticosteroid treatment. These drugs inhibit the function of T cells, which are an important component of the immune system. However, these drugs are slow to act, and a benefit may not be seen for 1 to 3 months. They also have potentially serious side effects that require close monitoring by the doctor.
Cyclosporine has been given to some people who have severe flare-ups and have not responded to corticosteroids. Most of these people respond initially to the cyclosporine, but some may still ultimately require surgery.
Tacrolimus is given by mouth. This drug has been given as short-term treatment to people whose ulcerative colitis is difficult to manage while they begin treatment with azathioprine and mercaptopurine. Tacrolimus may help maintain remission.
Biologic agents
Infliximab, which is derived from monoclonal antibodies to tumor necrosis factor (called a tumor necrosis factor inhibitor or TNF inhibitor) and given intravenously, is beneficial for some people with ulcerative colitis. This drug may be given to people who do not respond to corticosteroids or who develop symptoms whenever corticosteroid doses are lowered, despite the optimal use of other immunomodulating drugs. Infliximab, adalimumab, and golimumab are beneficial for people whose ulcerative colitis is difficult to treat or for people who depend on corticosteroids.
Side effects that may occur with infliximab include worsening of an existing uncontrolled bacterial infection, reactivation of tuberculosis or hepatitis B, and an increase in the risk of some types of cancer. Some people have reactions such as fever, chills, nausea, headache, itching, or rash during the infusion (called infusion reactions). Before starting treatment with infliximab or other TNF inhibitors such as adalimumab and golimumab, people must be tested for tuberculosis and hepatitis B infections.
Vedolizumab is a drug for people who have moderate to severe ulcerative colitis that has not responded to TNF inhibitors or other immunomodulating drugs or who are unable to tolerate these drugs. The most serious side effect it causes is increased susceptibility to infection. Vedolizumab has a theoretical risk of a serious brain infection called progressive multifocal leukoencephalopathy (PML) because this infection has been reported with the use of a related drug called natalizumab.