Ulcerative Colitis

What is Ulcerative Colitis?

The large intestine, known as the colon, begins at the cecum and terminates at the anus. It includes the ascending, transverse, descending and sigmoid colon along with the rectum. Ulcerative Colitis is an inflammatory bowel disease (IBD) that affects the inner lining of your colon. Colitis refers to inflammation of your colon and ulcerative refers to the development of ulcers at the sites of inflammation. Normally, the large intestine absorbs water from stool and changes it from a liquid to a solid. In UC, the inflammation causes loss of the lining of the colon, leading to bleeding, production of pus, diarrhoea, and abdominal discomfort.

Ulcerative colitis is a chronic condition that can cause life-threatening complications in severe cases. The symptoms of ulcerative colitis do not show up suddenly but tend to develop gradually over time. Ulcerative colitis commonly occurs during early childhood and adolescent life but can also occur during later life. People between the age group of 15 and 30 years most commonly experience the flares of ulcerative colitis. The risk of developing ulcerative colitis is higher in first degree relatives of the affected person.

Causes of Ulcerative Colitis

Our body’s immune system helps to protect us from contracting infections. It is believed that in patients with IBD, their immune system does not work properly and the intestinal bacteria are mistaken by your immune system as foreign invaders. As a result, the immune system directs white blood cells to the intestinal lining resulting in ulceration and inflammation at the intestinal site.

Classification of Ulcerative Colitis

Ulcerative colitis is classified based on the location of inflammation in the large intestine. Locations of inflammation include:

Entire colon: Pancolitis or Universal colitis
Rectum: Ulcerative Proctitis
Rectum and the left colon: Left-sided colitis
Rectum and the sigmoid colon (closest to the anus): Proctosigmoiditis
Severe inflammation in the entire colon: Fulminant colitis

Signs & Symptoms

The signs & symptoms of ulcerative colitis vary based on its location of occurrence and severity of inflammation. The signs and symptoms based on location include:

Ulcerative proctitis (rectum): Rectal inflammation, mild rectal bleeding, rectal pain, an urgency to defecate, and tenesmus (pain while bowels move).
Proctosigmoiditis (rectum and sigmoid colon): Diarrhoea with blood, tenesmus and abdominal pain and cramps.
Left-sided colitis (rectum and left colon): Pain on the left side of the abdomen, abdominal cramps, weight loss and bloody diarrhoea.
Pancolitis or universal colitis (entire colon): Bouts of severe bloody diarrhoea, fatigue, fever, weight loss, night sweats, abdominal cramps and pain.
Fulminant colitis (severe inflammation in the entire colon): Dehydration, severe abdominal pain, long period of diarrhoea with bleeding, and shock may occur. Severe complications such as colon rupture or dilatation may also occur.

You should consult your doctor if your bowel habits change frequently or if you experience the following symptoms:

Blood in stools
Diarrhoea that cannot be treated with over-the-counter medications
Fever for more than one or two days

Diagnosis

The diagnosis of Ulcerative colitis is carried out based on symptoms experienced. Your doctor will confirm the diagnosis by conducting a physical exam along with various medical tests.

Blood tests can reveal the count of red blood cells (RBCs) and white blood cells (WBCs) in your blood. Low RBC count indicates the presence of anaemia and intestinal bleeding, whereas an abnormal WBC count may indicate the presence of intestinal inflammation.

Stool tests may be ordered to assess for the presence of WBCs, viruses, bacteria and parasites that could be responsible for inflaming the colon. Stool tests can also detect a particular bacterial infection (Clostridium difficile) that commonly causes diarrhoea in patients with ulcerative colitis. Stool tests also help in identifying patients with a protein called calprotectin (an inflammatory marker) present in their stools.

Sigmoidoscopy and Colonoscopy are tests which help the doctor to view the lining of your colon and rectum. Your doctor will insert a thin, flexible tube attached to a lighted device and a camera. Your doctor will determine the severity of inflammation present in the colon and perform a biopsy by removing a tissue sample for laboratory analysis.

Barium enema X-ray is a test that takes X-ray images while barium contrast material is present in your colon. Your doctor will administer a chalky liquid into the rectum and colon. The barium contrast solution coats the lining of the colon which is then outlined on X-ray images.

Diagnostic tests such as video capsule endoscopy help in detecting small bowel disease in patients with ulcerative colitis who are suspected of having another type of IBD called Crohn's disease. Your doctor will have you to swallow a capsule containing a tiny camera. The capsule will pass through your intestine and the pictures taken will be transmitted to a recorder which will be reviewed by your doctor.

Standard imaging techniques as well as CT and MRI enterography using liquid contrast agents may be ordered to view the colon. Imaging studies determine the extent of the inflammation present in the colon.

Treatment

The inflammation may continue to worsen or resolve and may last for several months to years in patients with ulcerative colitis. Therefore, the main aim of treatment is to provide long term relief and reduce inflammation that may worsen signs and symptoms of the disease. Your doctor may prescribe medications or suggest surgery to treat ulcerative colitis.

Medications

Several classes of drugs may be prescribed to control inflammation in various ways.

Anti-inflammatory medications: Your doctor may prescribe anti-inflammatory medications as a first step of treatment to reduce inflammation.
Immune system suppressors: Since the intestinal lining becomes damaged due to the immune response, these drugs may be prescribed to target your immune system and reduce the inflammatory response.

Your doctor may also prescribe one or more medications to relieve your symptoms. These include:

Anti-diarrhoeal to treat severe diarrhoea
Antibiotics to control or prevent infections
Pain relievers to alleviate pain
Iron supplements to treat iron deficiency caused due to intestinal bleeding
Intravenous medications: Your doctor may administer corticosteroids intravenously to treat severe symptoms.

Surgery

Surgery is recommended if your symptoms are not relieved with other treatments such as lifestyle changes, diet or drugs. Your doctor may also suggest surgery in conditions such as colon rupture, colon cancer or profuse bleeding. Proctocolectomy is a surgical procedure performed to remove the entire colon and rectum. This procedure can be performed by using two techniques:

Ileostomy: The end of your small intestine (ileum) will be attached to a small opening (stoma) made in your abdomen. The waste material will be excreted and collected in a pouch worn over the stoma.
Ileoanal anastomosis: The inner muscles of the rectum are left behind after removal of the colon and part of your rectum. Your ileum will be connected to a pouch constructed inside your rectum. The pouch will be attached directly to the anus. Waste will be stored in this constructed pouch and excreted in a normal way through the anus.